Useful Forms for Our Patients
INTERNET FEEDBACK LINKS
Please consider posting some comments (hopefully positive!) about your experiences with our practice. Internet feedback is becoming more widespread, and most of the time people seem to post just the negative comments. We really appreciate your positive comments. Thank you for doing this for us.
APPOINTMENT REQUEST FORM
To request an appointment with Dr. Jick, Dr. Chang, or our Nurse Practitioner, Diane, just complete and submit the form below. For urgent requests, please call Dr. Jick's office at 626-304-2626. Dr. Jick, Dr. Chang 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.
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. You can be completely anonymous if you wish. However, for any urgent medical situations, please call the office. Information submitted through this method will be looked at as time permits.
The following forms are all in Adobe Acrobat (.pdf) format.
(They can be downloaded and printed out or read online.)
To obtain a free copy of Adobe Acrobat Reader, click here.
General Forms
PATIENT INFORMATION FORM
This form tells us all of your basic identification information, and how to reach you. We request that this form be filled out before the first office visit.
INSURANCE INFORMATION FORM
This form tells us what we need to know so we can verify your insurance coverage and bill insurance for you. We request that this form be filled out before the first office visit.
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 prenatal care you might have obtained prior to seeing us or any prior complicated pregnancies or deliveries.
PRACTICE PRIVACY NOTICE
A copy of this is given to all new patients at their initial visit. It decribes in detail what we may or may not do with your private health information.
PATIENT BILL OF RIGHTS
Our statement of your rights and responsibilities as our patient.
Obstetrics Patients
OB DATABASE FORM
This form is filled out by all new OB patients before the first prenatal appointment. It provides us with a comprehensive medical history, reviewed by the doctor before your OB Consult.
OB GUIDEBOOK
This comprehensive booklet is given to all of our OB Patients at their first prenatal visit.
L&D REGISTRATION FORM
This form needs to be filled out and sent to the hospital by your 7th month. You may leave the pediatrician field blank. If you print this as a 2-sided form, it can be mailed postage-paid.
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. Finally, give us the form and we will complete it and send it in for you.
Gynecology Patients
PATIENT INFORMATION FORM
This form tells us all of your basic identification information, and how to reach you. We request that this form be filled out before the first office visit.
INSURANCE INFORMATION FORM
This form tells us what we need to know so we can verify your insurance coverage and bill insurance for you. We request that this form be filled out before the first office visit.
GYN DATABASE FORM
This form is filled out by all new Gyn patients before the first appointment. It provides us with a comprehensive medical history, reviewed by the doctor before and during your initial visit
MARINA'S OASIS MENU
This is a menu of all of the luxurious and therapeutic skin care services available at Marina's Oasis.