Orange County Heart Institute

New Patients

Welcome to our practice—we’re here to make your first visit simple and comfortable. Our team will guide you through each step while we take the time to understand your needs and provide personalized care for your heart health.

Orange County Heart Institute and Research Center

New Patient Form

This field is for validation purposes and should be left unchanged.

Personal History

Address
Examples: hives, wheezing, nausea, etc. that you have experienced.

Family History

Please share any known health information for each parent.

Father

Mother

Family Conditions

Has any blood relative had any of the following conditions?

Health Habits

How many tobacco products do you typically use in 24 hours?

Were you exposed to second hand smoke in the past?

How many caffeinated beverages do you typically consume in 24 hours?

Do you drink alcoholic beverages?

Confidential Channel Communication Request

As required by the Health Information Portability and Accountability Act of 1996, you have the right to request that communications concerning your personal health information be made through confidential channels.

Please select all communication channels that apply*
Leave messages on my voice mail - Cell*
Leave messages with any other person*

Responsibility of Payment

Responsibility of Payment

By signing below, I understand that I am financially responsible for all services provided by Orange County Heart Institute. I understand that I am responsible for all payments whether there is insurance coverage or not. OCHI will bill my insurance as a courtesy only.

A holder of this medical debt contract is prohibited by Section 1785.27 of the Civil Code from furnishing any information related to this debt to a consumer credit agency.

If not signed by the patient, please indicate relationship:

Authorization for Release of Medical Information

To designate release of medical information please complete and sign this form.

Information we are allowed to give: Lab Results, Future Appointments, Medication Information i.e. last refill/refill request. No other information will be given.

You must have a power of attorney on file to allow a designated person to make changes to the care plan or request to speak to a provider or the assistant regarding any detailed medical information.

By signing this request, you are allowing this office to disclose certain information. We will only provide the information to your designated family member/s, spouse, relatives named by you below.

I have a power of attorney on file here at OCHI:*

This information is to be released for the purpose stated above and may not be used for any other purpose.

Schedule a Consultation

Ready to take the next step? Contact our friendly team to schedule a consultation today.