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.
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: afocdoctors@gmail.com
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.
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: afocdoctors@gmail.com
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.
For further information, please download the Patient Privacy HIPAA file listed above, and/or contact our office at 408-997-2020.
-Your Friendly Optometrists and Staff at
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.
For further information, please download the Patient Privacy HIPAA file listed above, and/or contact our office at 408-997-2020.
-Your Friendly Optometrists and Staff at
Almaden Family Optometric Center
