• Burbank Optometric Center, Inc.
    Adult Medical History - New and Established Patients


    New patients: Please fill out form completely.
    Established patients: Please provide any changes to your information
    and any new symptoms/problems/concerns.

  • Patient Information

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    Pick a Date
  • Emergency Contact

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  • Clear
  • INSURANCE: Please bring all insurance cards with you.

    Primary Vision Insurance

  • Secondary Vision Insurance

  • Primary Medical Insurance

  • Secondary Medical Insurance

  • SYMPTOMS: Check all that apply.

                   EYEGLASSES (Skip if you do not wear glasses)

  • CONTACT LENSES (Skip if you don't wear contacts)

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  • ELECTRONIC USE

  • MEDICAL HISTORY

  • Social History

  • Family Eye History

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  • Please return the completed questionnaire to us via your online portal at least one day before your appointment. Your login will be emailed to you. If you need assistance with your online portal, please call our office, 818-845-3549.


    THANK YOU!
    We look forward to seeing you soon!

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