SHINMORI OPTOMETRY -JAPANTOWN
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patient  forms

Patient Forms:
Please print out all 3 forms
Patient Information, Medical History, Reciept of Privacy Practices

patient_info_form.doc
File Size: 39 kb
File Type: doc
Download File

Take a moment to complete this Patient Information form prior to arrival for your first appointment with our office. After completing, please print and bring with you to your appointment.

medical_history_questionnaire_2019.pdf
File Size: 92 kb
File Type: pdf
Download File

The Medical Questionnaire allows us to obtain valuable medical history in order for us to better serve you. After completing, please print and bring with you to your appointment.

Receipt of Privacy Practices
File Size: 87 kb
File Type: pdf
Download File

This form acknowledges the review and consent to the Notice of Privacy Practices. Please sign and bring with you to your appointment.

Notice of Privacy Practices
File Size: 65 kb
File Type: pdf
Download File

You do not need to print and return this document. This is for your reference only. We are required by law to give you notice of our Privacy Practices which describes the uses and disclosures of your health information. The consent form requiring your signature is listed above, labeled "Receipt of Privacy Practices".
Contact Us
Shinmori Optometry
214 Jackson Street
San Jose, CA 95112
Phone: 408-293-3730
Office Hours
Mon    9:00 am - 6:00 pm
Tue     9:00 am - 6:00 pm
Wed    9:00 am - 6:00 pm
Thu     9:00 am - 6:00 pm
Fri       9:00 am - 6:00 pm
Sat      9:00 am - 4:00 pm
Notice of Privacy Practices
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  • Home
  • Our Practice
  • Our Services
    • Corneal Refractive Tx
    • Check your Insurance
  • Patient Forms
  • Eye Care Articles
  • Order Contact Lenses
  • Location