Mid-America Heart & Lung Surgeons


PATIENT INFORMATION SHEET

 
Patient Information
Sex

Marital Status

Race










 
Ethnicity


Spouse or Primary Insured Information
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

Add another Med?
Medication Allergies

Add another Allergy?
Prior Operations

Add another Procedure?
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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