Get a Copy of Discharge Notes at Burbank Urgent Care

Get Copy of Discharge Notes

Many times, our providers will give you a sheet of paper which summarizes your in -office visit. This sheet of paper is what we call the Discharge Notes. You can share the Discharge Notes with your Primary Care Provider. Or you can keep it for own benefit. The Discharge Notes commonly include the diagnosis, medication(s) prescribed, if applicable, the body vitals, and any procedures done.
Directions. Fill out this form. Our team will email it to you within 24 hours. Be sure to look for an email which contains @burbankurgentcare.com
What is the patient's name?*

First NameLast Name
What's the patient's date of birth?*

MonthDayYear
Date
What's your email?*
example@example.com
Confirm your email.*
example@example.com
What's your cell phone?*
Please enter a valid phone number.
Aproximate date you / the patient received care with Burbank Urgent Care?*

MonthDayYear
Date
Is the patient a minor?*
If yes, what is your name?

First NameLast Name
If yes, what is your relationship?
I testify that I am the patient and/or guardian of this patient.
Your Signature

First NameLast Name
Your Signature

Clear
Should be Empty:

Get Copy of Discharge Notes