Mid-America Heart & Lung Surgeons


ESTABLISHED PATIENT INFORMATION SHEET

 
Patient Information
Sex *

Marital Status *
Race










 
Ethnicity


Primary Insured Information
Is patient the primary insured?
Emergency Contact
Insurance Information
Do you have healthcare insurance? *

I also understand that I am financially responsible for all charges not covered by insurance.
I authorize my medical records from any healthcare facility be released to MidAmerica Heart and Lung Surgeons in order to assist in my care.
Signature of Patient or Authorized Person * – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 
Mid-America Heart & Lung Surgeons


REVIEW OF SYSTEMS

 
Personal History
Tobacco Use - Smoking *

Tobacco Use - Chew *

Alcohol Use *

Have you received both COVID-19 vaccinations? *

Medications
Are you taking any medications? *
Medication Allergies
Do you have any medication allergies? *
Prior Operations
Have you had any prior operations? *
Symptoms/Concerns Do you have any of the following symptoms or concerns?
General *





Skin *



Head, Eyes, Ears, Nose, Throat *






Respiratory/Breathing *




Heart *





Gastrointestinal *







Urinary *




Musculoskeletal *





Neurological *




Psychiatric *



Endocrine *



Hematology *




Latex Allergy *
Iodine/Contrast Allergy *
Will you accept blood products for surgery if needed? *
To the best of my knowledge the information provided above is correct and accurate:
Patient Signature * – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 
Mid-America Heart & Lung Surgeons


NOTICE OF PRIVACY PRACTICES

 
Would you like to read our Notice of Privacy Practices? *    
Mid-America Heart & Lung Surgeons


ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

 
I hereby acknowledge that I have received a copy of Mid America Heart & Lung Surgeons, P.C.’s Notice of Privacy Practices
Patient Signature * – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 
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