Patient Forms
Please complete the Medical History Form prior to your visit. This form can be completed by 1 of the 3 methods listed below:
This form will help our doctors to get to know our new patients better. For returning patients, please let us know if there are any changes to your medical history (including new medications, allergies, etc), insurance, mobile number, email and/or address when you are in the office or by texting us your full name and updates.
1. (Preferred Method) Check your email to get instructions on how to create a login to our office's secure Patient Portal AND enter in the requested medical history information, such as allergy, medication, personal/family history, etc. Please visit the Medical History tabs by clicking the menu bar icon located on the upper right corner of the screen (3 horizontal bars) and click on "MY HEALTH." Please complete ALL pages/tabs.
Once you have scheduled your eye exam appointment with us, you will have 72 hours to create a login to our office's patient portal.
If you did not get this email, please text our office at (408) 997-2020 your LAST, FIRST NAME + EMAIL to request for the Patient Portal registration to be sent again. Each person needs to have their own email to use the Patient Portal.
For minors, adult representative can be assigned to the child's portal if the child does not have his/her own email. In this situation, please text us adult representative's name and email, as well as the child's name. We will assign the USERNAME as following Last name + First name (example: SmithJohn) and the temporary PASSWORD as Last name + First name + 1 (example: SmithJohn1).
ONLY if you are unable to create a patient portal to enter your medical history information, please refer to option 2 or 3 as shown below. For returning patients wishing to update the medical record using the options below, please highlight the changes. Thank you.
2. For New Patients ONLY, please complete the form using the fillable pdf listed below, and email the form to our office at least 1 day prior to your appointment.
Our email address: [email protected]
Please use discretion when providing personal information via email.
3. For New Patients ONLY, print and bring the completed Medical History Form with you on the day of your eye exam. Please come 15 minutes prior to your appointment if you choose this option, so our team can enter the data to the computer before you see the doctor.
Please download the Medical History Form by clicking on the file below.
Computer Exam Questionnaire is optional.
This form will help our doctors to get to know our new patients better. For returning patients, please let us know if there are any changes to your medical history (including new medications, allergies, etc), insurance, mobile number, email and/or address when you are in the office or by texting us your full name and updates.
1. (Preferred Method) Check your email to get instructions on how to create a login to our office's secure Patient Portal AND enter in the requested medical history information, such as allergy, medication, personal/family history, etc. Please visit the Medical History tabs by clicking the menu bar icon located on the upper right corner of the screen (3 horizontal bars) and click on "MY HEALTH." Please complete ALL pages/tabs.
Once you have scheduled your eye exam appointment with us, you will have 72 hours to create a login to our office's patient portal.
If you did not get this email, please text our office at (408) 997-2020 your LAST, FIRST NAME + EMAIL to request for the Patient Portal registration to be sent again. Each person needs to have their own email to use the Patient Portal.
For minors, adult representative can be assigned to the child's portal if the child does not have his/her own email. In this situation, please text us adult representative's name and email, as well as the child's name. We will assign the USERNAME as following Last name + First name (example: SmithJohn) and the temporary PASSWORD as Last name + First name + 1 (example: SmithJohn1).
ONLY if you are unable to create a patient portal to enter your medical history information, please refer to option 2 or 3 as shown below. For returning patients wishing to update the medical record using the options below, please highlight the changes. Thank you.
2. For New Patients ONLY, please complete the form using the fillable pdf listed below, and email the form to our office at least 1 day prior to your appointment.
Our email address: [email protected]
Please use discretion when providing personal information via email.
3. For New Patients ONLY, print and bring the completed Medical History Form with you on the day of your eye exam. Please come 15 minutes prior to your appointment if you choose this option, so our team can enter the data to the computer before you see the doctor.
Please download the Medical History Form by clicking on the file below.
Computer Exam Questionnaire is optional.
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Dear Patients:
The Notice of Privacy Practices describes how your medical information may be used and disclosed, and how you can obtain access to this information. Please review it carefully.
We respect our legal obligation to keep health information, that identifies you, private. The law obligates us to give you notice of our privacy practices.
As a patient, you have the right to adequate notice of the uses and disclosures of your protected health information. Under the Health Insurance Portability and Accessibility Act (HIPAA), Almaden Family Optometric Center can use your protected health information for treatment, payment and healthcare operations.
We will prevent use or disclosure of your protected health information other than as provided for by the Patient Privacy HIPAA notice uploaded on this webpage. However, with your verbal, written or text consent, you can authorize our office to communicate with you through emails, phone calls and/or text messages, and that you are aware of the potential risk for breaches of unsecured protected health information transferred electronically.
We will not use your health information for marketing communications without your written authorization. However, our office will occasionally email our patients newsletters and updates, which you can choose to unsubscribe if you no longer wish to receive these emails. By providing our office with your mobile number, you are consenting to receive SMS text messages from Almaden Family Optometric Center. Message & data rates may apply. Patient can reply STOP to opt out at any time.
For further information, please download and refer to the Patient Privacy HIPAA document uploaded to this webpage or contact our office at (408) 997-2020.
~Almaden Family Optometric Center~
The Notice of Privacy Practices describes how your medical information may be used and disclosed, and how you can obtain access to this information. Please review it carefully.
We respect our legal obligation to keep health information, that identifies you, private. The law obligates us to give you notice of our privacy practices.
As a patient, you have the right to adequate notice of the uses and disclosures of your protected health information. Under the Health Insurance Portability and Accessibility Act (HIPAA), Almaden Family Optometric Center can use your protected health information for treatment, payment and healthcare operations.
We will prevent use or disclosure of your protected health information other than as provided for by the Patient Privacy HIPAA notice uploaded on this webpage. However, with your verbal, written or text consent, you can authorize our office to communicate with you through emails, phone calls and/or text messages, and that you are aware of the potential risk for breaches of unsecured protected health information transferred electronically.
We will not use your health information for marketing communications without your written authorization. However, our office will occasionally email our patients newsletters and updates, which you can choose to unsubscribe if you no longer wish to receive these emails. By providing our office with your mobile number, you are consenting to receive SMS text messages from Almaden Family Optometric Center. Message & data rates may apply. Patient can reply STOP to opt out at any time.
For further information, please download and refer to the Patient Privacy HIPAA document uploaded to this webpage or contact our office at (408) 997-2020.
~Almaden Family Optometric Center~
