626.716.9206
admin@healthylivingmedical.com

626.716.9206
admin@healthylivingmedical.com

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Home
Request Appointment
Medical Services
Meet Your Team
Patient Information
FAQs
Contact Us

Registration Form

Registration Form

Please complete registration form below. If you have insurance, please bring insurance card to your appointment.

Patient Information

Today's Date:(required)
Last Name:(required)
First Name:(required)
Marital Status:
Birth Date:(required)
Age:(required)
Sex:
Social Security:
Address:(required)
City, State, Zip Code:(required)
Home Phone:(required)
Cell Phone:
Email(valid email required)
Employement Status: (required)
Occupation:
Employer:
Employer Address:
Employer Phone:
How Did You Hear About Us? (required)
Reason For Today's Visit:(required)

Medical History

a. Illnesses: Select any that apply
High Blood Pressure Heart Disease Stroke
Migraines Diabetes Thyroid Disorder
Asthma Emphysema Breast Disease
Ulcers Hepatitis Kidney Disease
Venereal Disease Arthritis Depression
Other Illnesses
Other Illnesses:
b. Surgeries:
c. Allergies (and reactions):

Family Medical History

Select any that apply
High Blood Pressure Heart Disease Diabetes
Anemia Thyroid Disorder Breast Cancer
Colon Cancer Other Cancer Other Illnesses
Other Cancer
Other Illnesses
New Field
Patient Smoking Status
Patient Smoking Frequency
Patient Smoking Start Date
Patient Smoking End Date
How many alcohol drinks per week?
Current Medications:

Insurance Information (If applicable)

Insurance Name:
Primary Insured Name:
Relationship to Primary Insured:
Primary Insured Birth Date:
Insurance Id Number:
Group Number:
Plan Name:
Visit co-payment:

Emergency Contact

Contact name:(required)
Relationship: (required)
Contact address:(required)
Contact City, State, Zip code:(required)
Contact Home Phone:(required)
Contact Cell Phone:

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Healthy Living Medical or insurance company to release any information required to process my claims.
Type Full Name as Signature:(required)
Authorization Date:(required)

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Contact Us

Contact: 626.716.9206
Email: admin@healthylivingcardiology.com
Fax: 626.768.7657

Our Office Hours:

Monday – Thursday: 9:00am -5:00pm Friday: 9:00am – 4:00pm

Our Address: 301 S. Fair Oaks Ave. Suite 404, Pasadena CA 91105

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