Patient Resources and Forms
Pre-Registration & Medical History Forms
To speed up the registration process print and fill out the Pre-Registration & Medical History prior to visiting the clinic.
Los Angeles County COVID-19 Form
If you are coming in for Rapid or PCR testing, please complete and print out this form to bring in to the clinic.
Notice: To all Copy Services
All subpoenas or Authorization to copy must be served on DMS, Inc. This medical office is not authorized to accept service of any Subpoenas
Need Your Records Released?
To get started download and fill out the appropriate form, which authorizes Burbank Urgent Care to release your records. We recommend you use our forms below as they provide specific instructions and fees.
For Patient Use Only
To be Sent to Specialty Care Provider
To be Sent to Attorney / Law Office
Patient Code of Conduct at Burbank Urgent Care
Everyone should expect a safe, caring, and inclusive environment in all our spaces.
Our Patient Code of Conduct helps us to meet this goal.
Words or actions that are disrespectful, racist, discriminatory, hostile, or harassing are not welcome. Examples of these include:
- Offensive comments about others’ race, accent, religion, gender, sexual orientation, or other personal traits
- Refusal to see a clinician or other staff member based on these personal traits.
- Physical or verbal threats and assaults
- Sexual or vulgar words or actions
- Disrupting another patient’s care or experience
If we believe you have violated the Code with unwelcome words or actions, you will be given the chance to explain your point of view. We will always carefully consider your response before we make any decisions about future care at Burbank Urgent Care. Some violations of this Code may lead to patients being asked to make other plans for their care and future non-emergency care at Burbank Urgent Care may require review, though we expect this to be rare.
If you witness or are the target of any of these behaviors, please report it to a member of our staff.
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