New Patient Registration | Apogee Medical Associates

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Phone

Apogee Medical Associates, Interventional Cardiology
2852 Tamiami Trail Suite 4, Port Charlotte, Florida 33952
Phone: (941) 212-2748 Fax: (941) 328-8946

Chitradeep De, MD, MPH
Mayur Lakhani, MD, FACC
Anisleisys Vazquez, PA-C
Anuradha James, APRN+

Last Name *

First Name *

Address: *

Apt.

City: *

State: *

Zipcode: *

Patient Phone Number *

Email Address *

By entering I agree to receive medical and information emails from Apogee Medical Association.

Date of Birth *

Last Four Digits of SSN *

Gender

Female Male Other

Primary Language

Marital Status

Single Married Divorced Widow(er)

Race

Ethnicity

Emergency Contact Information

Emergency Contact:

Relationship:

Home Phone#

Cell Phone#

Guarantor Information (Responsible Party for bills, IF OTHER THAN PATIENT)

Date of Birth

Guarantor's Name:

Relationship to Patient

Self Spouse Child Other

If Other:

Work Phone #:

Cell Phone #:

Home Phone #:

Address:

City:

State:

Zipcode

Primary Insurance

Phone #:

Name of Primary Insurance

City:

Address:

Zipcode

State:

Copay $

Group #:

Policy #:

Effective Date

Phone #:

City:

Name of Secondary Insurance

Address:

Zipcode:

State:

Copay$

Group #:

Policy #:

Effective Date:

Phone #:

City:

Zipcode:

Pharmacy Name:

Address:

State:

Medical History

Today's Date:

Date of Birth:

Patient Name:

Current Medication

Please list dose and frequency if known.

10.

Past Medical History

Medical History

Heart Attack Diabetes Mellitus Cancer Peripheral Artery Disease Thyroid Problems High Blood Pressure High Cholesterol Chest Pain Mitral Valve Prolapse Kidney Trouble Angina Coronary Artery Disease Heart murmur HIV/AIDS Epilepsy/ Seizures Stroke Ulcers Hepatitis Asthma Tumors Other

Pacemaker

Yes No

Date of Implant

Make or Model

Allergies

Allergies to Medicine

Allergies to Food(s) or other(s):

Surgical History

If you do not recall day or month it is okay. Please be as accurate as possible.

Date:

Surgery:

Hospitalization

If you don't recall day or month it is ok. Please be as accurate as possible.

Date:

Surgery: