Patient Consent Form

Name

FIRST NAMELAST NAME

SEX

DATE OF BIRTH

Date

ADDRESS

PARISH

POSTAL CODE

WORK PHONE

HOME PHONE

MOBILE PHONE

EMAIL

example@example.com

EMPLOYERS NAME

MARITAL STATUS

OCCUPATION

PHYSICIANS NAME

MEDICATIONS

EMERGENCY CONTACT NAME

Phone

INSURANCE INFORMATION: Insurance Company Name:

Insurance Company Name

POLICY #

CERTIFICATE #

Your doctor has ordered a Cardiac Monitoring test for your heart. THIS IS A SAFE AND PAINLESS PROCEDURE. 3 electrodes will be attached to your chest and a cell phone like monitor will be provided. Please keep this device with you at all times. Your heart rate and rhythm will be monitored for a specified period - 24 hours up to 30 days. PLEASE DO NOT GET THE MONITOR WET. If wearing the device for an extended period, you will be allowed to remove the monitor to bathe. The monitor should be immediately re-attached to your chest when dry. When the monitoring period has ended, you will be required to remove and return the monitor along with the accessory case. A report of the results will be sent to your referring doctor. PRIVACY - We are committed to adhering to all PIPA guidelines regarding protection of your personal information. Please request to see our Privacy Policy at CardioCare Diagnostics. I do hereby agree and give my consent to the Cardiac Monitoring test provided by CardioCare Diagnostics. I do hereby agree that I am responsible for any charges not immediately covered by my insurance provider or if I do not have insurance. All outstanding charges will accumulate a 2% interest fee after 90 days. I do hereby agree that in the event the Cardiac Monitor is damaged, destroyed or lost during the testing period, I will be responsible for all costs associated with its replacement - $1500.

PATIENT SIGNATURE

DATE SIGNED