Patient Forms

Patient Forms

Welcome to MemorialCare Medical Group. For your convenience, please print and fill out all applicable forms and present them to the front desk when you arrive for your first office visit.

English

• Patient Registration Forms.pdf
• myChart Adult Proxy Form (english).pdf
• myChart Child Proxy Form (english)

Español

• Registro de Pacientes - Español
• myChart Adult Proxy Form - Español
• myChart Child Proxy Form - Español

Advance Health Care Directive

MemorialCare Medical Group/MemorialCare recommend completing an Advance Directive/Medical Power of Attorney/Living Will/Physician Order for Life-Sustaining Treatment (POLST) form on file in your medical record. See Palliative Care & Planning for more information.

Use these forms to obtain your records from MemorialCare or UCI Health, or to have them sent to MemorialCare from another health provider.

• Authorization for Release of Medical Records - MCMG - English
• Authorization for Release of Medical Records - MCMG - Spanish
• Authorization for Release of Medical Records - UCI

Use this form to opt-out of the MemorialCare Health Information Exchange

• MCMG-Patient Opt-Out Request Form 2019.pdf
• MCMG-Patient Opt-Out Request Form 2019-Spanish.pdf

If you have any questions or you need more information, please contact our Medical Records Department at (714) 665-1647 or by FAX at (714) 665-1644.