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At Dr. Shameem Khan Optometrist, Inc., we value your time. In an effort to save you time in our office, you can download and complete our patient form(s) prior to your appointment.

  • You will need AdobeReader® to download and complete the forms. Click here to download.
  • Download the required form(s). Print out the form(s) and complete the required information.
  • Fax your printed and completed form(s) to our office or bring them with you to your appointment.

New Patient Health History Form – Required

Please complete this form as it lets us know the history and current state of your health. Let us know what questions, concerns, and goals your have regarding your eye health or vision on the form.

Download & Print Form

Nuevo Formulario de Historia de Salud del Paciente – Requerido

Por favor, complete este formulario , ya que nos permite conocer la historia y el estado actual de su salud. Háganos saber lo que preguntas , preocupaciones y objetivos de su haber con respecto a su salud de los ojos o la visión en el formulario.

Download & Print Form

Download the Free AdobeReader®

THIS ---->https://shameemkhanod.imatrixbase.com/online-forms.html

Office Hours

Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
9:00am 9:00am 9:00am 9:00am 9:00am 10:00am Closed
5:30pm 5:30pm 5:30pm 5:30pm 5:30pm 2:00pm Closed


I am a City of Chino Hills employee and I went to Dr. Khan for a regular eye exam.  Both her and her staff were very professional, efficient  and extremely patient with all my questions and concerns.  The whole process from the exam to getting my first pair of glasses went smoothly.  I highly recommend her to all my other colleagues, friends and relatives.  Actually my husband also made his appointment with Dr. Khan and was extremely pleased by the service received.  Thank you Dr. Khan and your staff!  You're awesome.

- S.A

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