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Located in the Japantown area of San Jose,
on Jackson Street between N. 5th and N. 6th Streets.

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408-293-3730
formerly Shinmori Optometry
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Home ยป Patient Forms

Patient Forms

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

Patient Information Form

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 Form

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

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

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”.