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
*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 would like to read our Notice of Privacy, please Click Here
Authorization to Share Protected Health Information (PHI):
Patients may choose to allow Burke Optometry to share their Protected Health Information (PHI) with designated family members or caregivers. To ensure your privacy and comply with federal regulations, we require a signed consent form before any information can be released. Please complete the authorization form if you would like us to share your PHI with someone you trust.
PHI form Click Here
Autorización para Compartir Información de Salud Protegida (PHI):
Los pacientes pueden optar por permitir que Burke Optometry comparta su Información de Salud Protegida (PHI) con familiares designados o cuidadores. Para garantizar su privacidad y cumplir con las regulaciones federales, necesitamos un formulario de consentimiento firmado antes de divulgar cualquier información. Por favor, complete el formulario de autorización si desea que compartamos su PHI con alguien de su confianza.
PHI form Haga clic aquí
If you would like to have a printable format of our Notice of Privacy, please Click Here
Please read our No Show/Late Cancellation Policies Click Here