Gift of Life-AZ

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Patient Application

New Patient Application

Download a New Patient
Application (PDF)

New Patient Application -
Español

Download a New Patient
Application - Español (PDF)

New Patient Application

Requirements

• New Patient Application
• Initial diagnostic evaluation by referring physician
• Medical progress notes (dated within six months of application)
• Electrocardiogram (ECG / EKG)
• Chest x-ray Cardiac Cath Report(s) and if possible films/VHS tape

Patient

*Required

First Name*

Middle Name

Last Name*

Suffix

Date of Birth*

Sex* Male Female

Weight pounds

Height feet inches

Email*

Phone*

Street 1*

Street 2

City*

State/Province*

ZIP/Postal Code*

Country*

Mother's Full Name*

Father's Full Name*

Patient Referred By

Patient's Siblings

Sibling #1

Full Name

Date of Birth

Sex

Sibling #2

Full Name

Date of Birth

Sex

Sibling #3

Full Name

Date of Birth

Sex

Patient History

Vaccinations*

Allergies*

Medication Allergies*

Previous Surgeries*

Previous Hospitalizations*

Current Medications*

Cardiac Diagnosis*

Other Illnesses*

Explain in details what heart problems patient presents*

Family History

Do any BLOOD relatives (parent, brother, sister, or other blood relatives) have any of the following problems? Please state who is affected.

Heart Murmur

Hypertension

High Cholesterol Level

Death Due to Heart Disease

Other Heart Problems

Diabetes

Rheumatic Fever

Congenital Malformation

Financial Information

Father's Employer*

Employer's Address

Employer's Phone Number

Length of Employment

Job Title

Mother's Employer*

Employer's Address

Employer's Phone Number

Length of Employment

Job Title

Household Annual Income*

Immigration Issues

Please indicate if patient and escort have the following required documents.

	Patient	Escort
Passport	YesNo	YesNo
Visa	YesNo	YesNo
Permit	YesNo	YesNo
None	YesNo	YesNo
Other	YesNo	YesNo

Requirements

Please submit the following in order for your application to proceed faster (if applicable):

Initial diagnostic evaluation
Medical progress notes (dated within six months of application)
Electrocardiogram (ECG / EKG)
Echocardiogram (include video tape)
Chest X-Ray
Cardiac cath report(s) and if possible films

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