Cardiology Information Request Form

Discover Our Treatments & Programs at Miskawaan Health Group

  • Patients Details
  • DD slash MM slash YYYY

  • Medications
  • We would like to draw your attention that we may require your medical reports, diagnosis and any other relevant information. With this information we can try to help you further.

  • What is the history of presenting problem or Illness?
    Is there any chest discomfort? If yes...

  • Risk factors
  • DD slash MM slash YYYY

  • Cholesterol

  • Family history Is there any history of cardiovascular disease in your family?

  • Mother

  • Siblings
  • Are you a regular drinker?
  • Marital status
  • (Please check if applicable)
  • Please provide us with the following reports if you have them available. To upload the documents simply click the upload button and select the file to upload from your browser. (Each file size should not over 3MB and total file sizes should not over 15MB)
  • Drop files here or
    Accepted file types: pdf, png, jpg, jpeg, zip, Max. file size: 10 MB.
    • Drop files here or
      Accepted file types: pdf, png, jpg, jpeg, zip, Max. file size: 10 MB.
      • Drop files here or
        Accepted file types: pdf, png, jpg, jpeg, zip, Max. file size: 10 MB.
        • I confirm that the information provided in this questionnaire is an honest and realistic description of my/the patient's current health state. I understand that if my/the patient's health state on arrival differs significantly from the description given in this questionnaire, Miskawaan Health Group has the right to decline treatment and this may result in already paid costs not being refunded to me.

          Release and management of medical information: I understand that my medical information and records are kept confidential by Miskawaan Health Group.

          I agree and consent that Miskawaan Health Group may disclose all or any part of my medical records to a referring physician, hospital, clinic and/or medical center for the purpose of discharging their duties.

          I agree to release and hold harmless Miskawaan Health Group and its agent, representatives, employees from any and all liability associated with the disclosure of confidential patient information as authorized in this consent agreement and I do agree that Miskawaan Health Group is not responsible for the use or non-authorized disclosures of information by other to whom I have consented disclosures of my confidential information.

          I acknowledge that my medical information, treatment and all its history in kept in medical and electronic medical record. If I do not receive services or treatment from Miskawaan Health Group for 5 consecutive year, my medical records and other treatment records (including imaging records) may be deleted and/or destroy.

          I understand that this consent agreement will be valid and remain in effect as long as I am engaged with Miskawaan Health Group unless revoked by me in a written notice to the Authorized officer of Miskawaan Health Group.

          I certify that I have read and understand this consent agreement and accept all of its contents.

        • DD slash MM slash YYYY