Healthy Hearts Patient Information Please choose your office* ENCINO MISSION HILLS VALENCIA WESTWOOD Patient Name* HiddenAccount 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:* MM slash DD slash YYYY Email Address Marital Status* Single Married Divorced Widow Separated 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* MM slash DD slash YYYY Signature of authorized person*FInancial Agreement and Information Date* MM slash DD slash YYYY Signature of insured/authorized person*
