Healthy Hearts Patient Information Please choose your office*ENCINOMISSION HILLSVALENCIAWESTWOODPatient Name*AccountHome Address1*Home Address2Home Address3Are you a resident of a skilled nursing or board and care facility?YesNoPatient’s Home #:Patient's Work #:Patient's Cell #:Preferred Contact NumberHomeWorkCellSex*MFOtherPatient's Date Of Birth:* Date Format: MM slash DD slash YYYY Email Address Marital Status*SingleMarriedDivorcedWidowSeparatedIf married, name & date of spouse:Patient's Employer:OccupationEmergency Contact Name*Emergency Contact Phone#*Referred By:*Primary Care Physician Name:Primary Care Physician:UnknownNoneHow did you hear about us?Ethnic Classification*Hispanic or LatinoNon-Hispanic or LatinoDeclinedUnknownRace*American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteDeclinedUnknownPreferred Language*Preferred Pharmacy Name*Preferred Pharmacy Address 1*Preferred Pharmacy Address 2Preferred Pharmacy Address 3Preferred 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. NameI 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?*YesNoSignature of patient*Consent Date* Date Format: MM slash DD slash YYYY Signature of authorized person*FInancial Agreement and Information Date* Date Format: MM slash DD slash YYYY Signature of insured/authorized person*
