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.

New Gynecologic Patients Will Need These Forms

• Intake Form (63K pdf file, 2 pages)
• Registration Form (64K 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 (63K pdf file, 2 pages)
• Obstetrical Screening (46K pdf file, 1 page)
• Registration Form (64K 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—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 (46K pdf file, 1 page)
• Registration Form—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)

Updated 3/21/08

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Anjali Tate, M.D., Loma Vista Obstetrics & Gynecology
2577 Samaritan Drive, Suite 810, San Jose, CA 95124, 408.358.1888; Fax-408.356.0877. Email Dr. Tate

Notice of Privacy Practices - Copyright 2008, Anjali Tate, MD - Website by CommCraft.