Useful Forms (and articles) for Our Patients

NEW OB PATIENTS - please click here for your forms.

NEW GYN PATIENTS - please click here for your forms.

Online Forms

The following forms can be filled out and submitted online

POST AN ONLINE REVIEW
Here is an easy way to for you to post a review of our practice for others to read.

APPOINTMENT REQUEST FORM
Click here to request an appointment with Dr. Jick, Dr. Park, Dr. Fong, Dr. Mitri, Dr. Woo  or Diane, our Nurse Practitioner.

For urgent requests, please call the office at 626-304-2626. 

Dr. Jick, Dr. Park, Dr. Fong, Dr. Mitri, Dr. Woo and Diane are all available for new patients.

PRESCRIPTION REFILL REQUEST FORM
All prescription refill requests will be processed within 1-2 business days after being received. For hormone or birth control refills, your annual exam and pap smear should be up to date or you should have a scheduled appointment soon. 

*Please - do NOT call the on-call doctor for an emergency refill request. This is not a medical emergency.

The best source for this required information is the label attached to your current prescription.
For urgent needs, please call the office directly at (626) 304-2626.

COMMENTS FORM
Use this form to send us feedback about anything. However, for any urgent medical situations, please call the office. Comments will be looked at as time permits.

General Forms

(all of these are in pdf format)

 

RECORDS REQUEST FORM
This form can be filled out and sent to any physician or hospital that has records that you would like copied and sent to us. Use this for any care you might have obtained prior to seeing us that you think we might want to review.

PRACTICE PRIVACY NOTICE
A copy of this is given to all new patients at their initial visit. In compliance with the federal law known as HIPPA, it describes in detail what we may or may not do with your private health information (PHI).

PATIENT BILL OF RIGHTS
Our statement of your rights and responsibilities as our patient.

RECORDS COPY
You can have a copy of your medical records sent either to you personally or to a designated physician. Use this form, fill it out, sign and date it, and then mail it to us. There is a $30 one-time fee.

Obstetrics Patients

OB GUIDEBOOK - Welcome to Our Practice
This comprehensive booklet is given to all of our OB Patients at their first prenatal visit.
Click here to go to the online version of this OB Guidebook.

MULTIPLE GESTATION ARTICLE
This article discusses our philosophy on how we manage twins and triplets.

Labor and Delivery (L&D) REGISTRATION FORM
This form should be filled out and sent to the hospital by your 7th month of pregnancy.

CALIFORNIA STATE DISABILITY FORM
This form is used to apply for California State Disability (SDI) benefits. DO NOT submit this form until you have actually STOPPED working. Then fill out your portion including the last day that you worked.  After that, just give us the form and we will complete it and send it in for you

Gynecology Patients

GYN BOOKLET - Welcome to Our Practice
This booklet explains tells you about our practice, the doctors and staff and our policies and procedures.