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2. Instructions

   Please fill out this form before your first visit. If you do not have time to do that, you can do so at your appointment. 

   
   

4. Today's Date*
   Today's Date
6. Referred by

   1. WIC
   2. Health Department Medical Clinic
   3. Friend
   4. Other
8. If other, please tell us who referred you to our services.
10. Head of Household Information
12. First Name*
13. Middle Initial
14. Last Name*
16. Maiden Name
17. Birth Date*
    Birth Date
19. Sex

    1. Male
    2. Female
    3. X (Nonbinary and/or Intersex)
21. Ethnicity

    1. American Indian or Alaska Native
    2. Asian
    3. Black or African American
    4. Hispanic

    1. Native Hawaiian or other Pacific Islander
    2. White
    3. Other
23. Address*
25. City*
26. State
27. Zip Code
29. Email Address
31. Mailing Address (if different from above)
33. Address
35. City
36. State
37. Zip Code
39. Phone Number*

    1. Home
    2. Cell
    3. Work

    Select the phone number you would like us to use to contact you. 

40. Phone Number*

    Please provide your phone number here.

42. How would you like to receive appointment reminders?

    1. Email. If you choose email, please provide that address above.
    2. Text. If you choose texts, please provide your cell phone number above.
44. If you are registering children, what is your relationship to the children?
46. Would you like an interpreter for your appointment?*

    1. Yes
    2. No
47. Preferred Language
49. Acknowledgement of Receipt of Privacy Practices (NPP)

    I hereby acknowledge that I have received, or have been given a chance to review, a copy of the Orange County Health Department Notice of Privacy Practices. I understand that I may contact the department’s Privacy Officer if I have a complaint, questions, or concerns.

50. Please provide your initials.*

    We will ask for your signature at your appointment.

52. Household Contact and Income Verification Information

    List all members of your household that receive and share income. Begin with providing your information. 

    Note: You need to update this page each year or when there is a change in your income or family size.

54. Name*
55. Date of Birth*
    Date of Birth
56. Relationship*
57. Annual Income*
59. Insurance Information*

    1. No insurance (self-pay)
    2. Medicaid
    3. Private insurance
61. Name
62. Date of Birth
    Date of Birth
63. Relationship
64. Annual Income
66. Insurance Information

    1. No insurance (self-pay)
    2. Medicaid
    3. Private insurance
68. Name
69. Date of Birth
    Date of Birth
70. Relationship
71. Annual Income
73. Insurance Information

    1. No insurance (self-pay)
    2. Medicaid
    3. Private insurance
75. Name
76. Date of Birth
77. Relationship
78. Annual Income
80. Insurance Information

    1. No insurance (self-pay)
    2. Medicaid
    3. Private insurance
84. Affirmation

    I hereby affirm that, to the best of my knowledge, the income information I have provided is true and correct. I understand that my signature will serve as my official legal signature on file for the income information submitted.

85. Please provide your initials.*

    We will get your signature during your appointment.

    
    

87. Name of interpreter
88. Interpreter's Initials

    We will get the interpreter's signature during your appointment. 

89. Date
    Date
Leave This Blank:


91. 1. Receive an email copy of this form.
92. Email address

    This field is not part of the form submission.

93. Submit

* indicates a required field