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.

Intake form (New due to COVID-19): Click Here

Formulario de admisión: Clic aquí

Medical history questionnaire (English): Click Here
For our fillable Medical history questionnaire please click on:
Medical history questionnaire

Cuestionario Médico del Paciente: Clic aquí
Para nuestro Cuestionario Médico del Paciente rellenable, haga clic aquí:
Cuestionario Médico del Paciente

Consent form (English): Click Here
For our fillable Consent form please click on:
Consent Form

Acta de conocimiento: Clic aquí
Para nuestra Acta de conocimiento rellenable, haga clic aquí:
Acta de conocimiento

InfantSEE history form (English): Click Here

InfantSEE historia del niño/a : Clic aquí

*If you are a contact lens user, you can check these forms:

Contact Lens Fees and acknowledgement form

Contact Lens Instruction form

*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

If you would like to have a printable format of our Notice of Privacy, please Click Here