Healthy Hearts – Healthy Hearts Patient Information

Please choose your office*

ENCINO
MISSION HILLS
VALENCIA
WESTWOOD

Patient Name*

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Account

Home Address1*

Home Address2

Home Address3

Are you a resident of a skilled nursing or board and care facility?

Yes
No

Patient’s Home #:

Patient's Work #:

Patient's Cell #:

Preferred Contact Number

Home
Work
Cell

Sex*

M
F
Other

Patient's Date Of Birth:*

Email Address

Marital Status*

If married, name & date of spouse:

Patient's Employer:

Occupation

Emergency Contact Name*

Emergency Contact Phone#*

Referred By:*

Primary Care Physician Name:

Primary Care Physician:

Unknown
None

How did you hear about us?

Ethnic Classification*

Hispanic or Latino
Non-Hispanic or Latino
Declined
Unknown

Race*

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Declined
Unknown

Preferred Language*

Preferred Pharmacy Name*

Preferred Pharmacy Address 1*

Preferred Pharmacy Address 2

Preferred Pharmacy Address 3

Preferred Pharmacy Phone Number*

1. Name*

I authorize CARDIOVASCULAR CONSULTANTS MEDICAL GROUP physicians and staff to disclose to and discuss my protected health information with the following (e.g. family member, friend) person or persons in addition to my other health care providers

2. Name

I authorize CARDIOVASCULAR CONSULTANTS MEDICAL GROUP physicians and staff to disclose to and discuss my protected health information with the following (e.g. family member, friend) person or persons in addition to my other health care providers

I prefer no one to have access to my health information without my written consent except where allowed by law?*

Yes
No

Signature of patient*

Consent Date*

Signature of authorized person*

FInancial Agreement and Information Date*

Signature of insured/authorized person*