Cardiovascular Medical Group of Southern California

Medical Intake Form

Please complete this form to help us prepare for your appointment. All information is confidential.
Patient Information

Please provide your personal details.
Full Name (Legal name)

First NameLast Name
Date of Birth

MonthDayYear
Date
Sex
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Health Insurance Provider (if any)
Enter your insurance provider (e.g., Blue Shield PPO, Aetna HMO)
Follow-Up Care Acknowledgment and Consent

Please read the following carefully before submitting your information.
I understand that the Coronary Artery Calcium (CAC) scan is one component of my cardiovascular evaluation. I agree to provide a copy of my scan results to my primary care physician or other treating healthcare provider and to review the results with them so they can advise me regarding any appropriate follow-up, additional testing, or treatment based on my overall medical history. I understand that the Eli Baitelman Heart Foundation and the interpreting physician are not responsible for providing my ongoing medical care or treatment recommendations
Signature
By typing/signing your name and submitting this form, you acknowledge that this electronic signature confirms your agreement with the statement above.
Should be Empty:

Medical Intake Form