Office Hours

• Monday - Friday
• 8:00AM to 5:00PM

    Call for Appointments

• Monday - Friday
• 8:30AM to 5:00PM

    Office Will be Closed

• Thursday - 11/24/11
• Friday - 11/25/11
• Friday - 12/23/11
• Friday - 12/30/11

Se Habla Espanol

Conversational Mandarin

To save time, please download the appropriate forms and bring completed copies to your appointment.

You will need Adobe^® Acrobat reader to view and print out the forms. If you do not have a reader, you can obtain a free copy through this link.

Forms Needed if You:

• Are a New Gynecologic Patient
• Are a New Obstetric Patient
• Are a Returning Gynecologic Patient
• Are a Returning Obstetric Patient
• Want the NOVASURE/Heavy menstrual bleeding questionnaire
• Want the Urinary tract infection instructions
• Are Requesting Medical Records from Loma Vista

New Gynecologic Patients Will Need These Forms

• Intake Form (37K pdf file, 3 pages)
• Registration Form (26K pdf file, 1 page)
• Loma Vista Financial Policy (13K pdf file, 1 page)
• Acknowledgment of Receipt of Notice of Privacy Practices Form (38K pdf file, 1 page)
• Please note that the Acknowledgment of Receipt of Notice of Privacy Practices Form states that you have received and read the Notice of Privacy Practices (22K pdf file, 5 pages). Please download and read before completing the form. (The Notice of Privacy Practices is also available as a HTML page through this link.)

New Obstetric Patients Will Need These Forms

• Intake Form (37K pdf file, 3 pages)
• Obstetrical Screening (138K pdf file, 1 page)
• Registration Form (26K pdf file, 1 page)
• Loma Vista Financial Policy (13K pdf file, 1 page)
• Acknowledgment of Receipt of Notice of Privacy Practices Form (38K pdf file,
  1 page)
• Please note that the Acknowledgment of Receipt of Notice of Privacy Practices Form states that you have received and read the Notice of Privacy Practices (22K pdf file, 5 pages). Please download and read before completing the form. (The Notice of Privacy Practices is also available as a HTML page through this link.)

Returning Gynecologic Patients Will Need These Forms

• Registration Form (26K pdf file, 1 page)—This should be completed and signed once a year or when insurance, employer, address, or name has changed (64K pdf file, 1 page)
• Loma Vista Financial Policy (13K pdf file, 1 page)
• Acknowledgment of Receipt of Notice of Privacy Practices—If not already signed (38K pdf file, 1 page)
• Please note that the Acknowledgment of Receipt of Notice of Privacy Practices Form states that you have received and read the Notice of Privacy Practices (22K pdf file, 5 pages). Please download and read before completing the form. (The Notice of Privacy Practices is also available as a HTML page through this link.)

Returning Obstetric Patients Will Need These Forms

• Obstetrical Screening (138K pdf file, 1 page)
• Registration Form (26K pdf file, 1 page)—This should be completed and signed once a year or when insurance, employer, address, or name has changed (64K pdf file, 1 page)
• Loma Vista Financial Policy (13K pdf file, 1 page)
• Acknowledgment of Receipt of Notice of Privacy Practices—If not already signed (38K pdf file, 1 page)
• Please note that the Acknowledgment of Receipt of Notice of Privacy Practices Form states that you have received and read the Notice of Privacy Practices (22K pdf file, 5 pages). Please download and read before completing the form. (The Notice of Privacy Practices is also available as a HTML page through this link.)

Optional Forms/Information Pages

• NOVASURE/Heavy menstrual bleeding questionnaire(19K pdf file, 1 page)
• Urinary tract infection instructions (19K pdf file, 1 page)
• Patient Request to Access Health Information From Loma Vista Ob/Gyn Medical Group, Inc. (25 K pdf file, 1 page)

Updated: 1/23/12

Loma Vista Obstetrics & Gynecology Medical Group
2577 Samaritan Drive, Suite 810, San Jose, CA 95124 - Phone: 408.358.1888 - Fax:408.356-0877

^©2012 Loma Vista Obstetrics & Gynecology Medical Group - Notice of Privacy Practices