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Open : 8am - 5pm (Mon - Fri)
Mckinney Office
Dallas Office
214-504-9942
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Services we offer
POTS Treament
Diagnostic Testing Services
Autonomic Nervous System Testing
Metabolic Stress Testing
Echocardiography
24-Hour Blood Pressure Monitoring
Assessment of Forearm Blood Flow
P Wave Signal Averaging
Carotid Doppler
Lipid Profile
EECP
Pulmonary Function Tests
Vascular Testing
Signal Average EKG
Stress Test
Thyroid Function Tests
Holter Monitor
Tilt Table Testing
About Us
About Dr. Suleman
Our Team
Heartbeat Clinic Journal
Start Televisit
Locations
McKinney
Dallas
Contact us
More
Patient Forms
Blogs
Home
Services we offer
POTS Treament
Diagnostic Testing Services
Autonomic Nervous System Testing
Metabolic Stress Testing
Echocardiography
24-Hour Blood Pressure Monitoring
Assessment of Forearm Blood Flow
P Wave Signal Averaging
Carotid Doppler
Lipid Profile
EECP
Pulmonary Function Tests
Vascular Testing
Signal Average EKG
Stress Test
Thyroid Function Tests
Holter Monitor
Tilt Table Testing
About Us
About Dr. Suleman
Our Team
Heartbeat Clinic Journal
Start Televisit
Locations
McKinney
Dallas
Contact us
More
Patient Forms
Blogs
Request An Appointment
Patient Information
Step
1
of
4
25%
PCP:
Phone:
Referring:
Phone:
Patient’s
*
First
Middle
Last
Title
Mr.
Mrs.
Dr.
Miss
Ms.
Is this your legal name?
Yes
No
If not, what is your legal name?
(Former name):
Marital status (circle one)
Single
Married
Divorced
Separated
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Other
Birth date:
Day
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Age:
Sex:
M
F
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Home phone no.:
Cell phone no.:
Social Security Number:
Email:
*
Employer and Occupation:
Employer phone no.:
Referred to clinic by (please check one box):
Dr.
Insurance Plan
Hospital
Family
Friend
Close to home/work
Yellow Pages
Other
Other family members seen here:
INSURANCE INFORMATION
(Please give your insurance cards and drivers license to the receptionist)
Person responsible for bill:
Birth date:
MM slash DD slash YYYY
Address (if different):
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home phone no. (if different):
Is this person a patient here?
Yes
No
Occupation:
Employer:
Employer address:
Employer phone no.:
Is this patient covered by insurance?
Yes
No
Please indicate primary insurance
Medicare
Medicaid
Blue Cross
Cigna
Humana
Aetna
United Health Care
Tricare
Secure Horizon
Other
Subscriber’s name:
Subscriber’s S.S. no.:
Birth date:
MM slash DD slash YYYY
Group no.:
Policy no.:
Co-payment:
Patient’s relationship to subscriber:
Self
Spouse
Child
Other
Name of secondary insurance (if applicable):
Subscriber’s name:
Group no.:
Policy no.:
Patient’s relationship to subscriber
Self
Spouse
Child
Other
IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address):
Relationship to patient:
Home phone no.:
Cell phone no.:
Patient/Guardian signature
Date
MM slash DD slash YYYY
Policies & Consents
Please read and review carefully, then sign and date.
Patient Name:
Date of Birth:
MM slash DD slash YYYY
Patient Signature / Responsible Party
Date
MM slash DD slash YYYY
Witness Signature
REQUEST FOR RELEASE OF PATIENT HEALTH CARE INFORMATION
Patient Name:
DOB:
MM slash DD slash YYYY
1. Full Name
Relationship:
Contact Number:
2. Full Name:
Relationship:
Contact Number:
3. Full Name:
Relationship:
Contact Number:
Please check this box if you wish
NOT
to have any health care information released at this time.
1. Full Name:
Relationship:
Contact Number:
2. Full Name:
Relationship:
Contact Number:
In the event I am called, but not available, I herby give the right for The Heartbeat Clinic to
Leave a detailed voice message. Best number to be reached is
Leave only a general voicemail
Patient Signature:
Date:
MM slash DD slash YYYY
First Name
Last Name
Email
Phone
Date of Birth
Patient Address
City
Zip Code
Reason For Contact
Other
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