Forms

As part of your registration as a patient at Burke Optometry, we will require you to complete a medical history questionnaire. We will also need you to sign our yearly consent form. In order to save time, you can fill them out at home and bring in a printed copy to your appointment at the office. Below are the links to the necessary forms.

Medical history questionnaire (English): Click Here

Medical history questionnaire (Español): Click Here

Consent form (English): Click Here

Consent form (Español): Click Here

InfantSEE history form (English): Click Here

InfantSEE history form (Español): Click Here

*If you are an adult or if you are bringing your child over 3 year we will need you to bring the Medical history questionnaire and the Consent form filled out.

*If you have a baby between 6 – 12 months coming in for the free InfantSEE exam please feel out the InfantSEE history form and the Consent form.

If you would like to read our Notice of Privacy, please Click Here

441 S Ham Ln, Ste B. Lodi, CA 95242 schedule@burkeoptometry.com 209-224-5454