This field is for validation purposes and should be left unchanged.

Patient Information

Patient Name(Required)

As our patient, we may need to reach you when you are not in the practice. For your privacy, indicate how we may communicate confidential medical information such as laboratory results, test results, or appointments. Appointment reminder telephone calls or text messages may be sent to the contact information entered below.

By entering a number or email address, you give Premier Heart permission to leave or send medical information pertaining to you, your dependent, or your child according to the selection made for that method.

Communication Preferences

May we leave a voice message at the home telephone?
May we leave a voice or text message at the mobile phone?
May we leave a voice message at the work phone?
May we send confidential medical information by email?

People Authorized to Receive Medical Information

Without specific permission, medical information will not be released to anyone other than the patient. List any people who may receive information.
Authorized Person 1 – May we leave a message?
Authorized Person 2 – May we leave a message?
Authorized Person 3 – May we leave a message?
Authorized Person 4 – May we leave a message?

I assume responsibility for informing the practice of changes to my phone numbers or communication preferences, or for revoking this authorization at any time.

Communication Authorization(Required)
Who is signing?(Required)
Type your full legal name. This serves as your electronic signature.
Print Signer's Name(Required)