New Patient Forms

In Case Of Emergency
Name*
First Last
Relationship To Patient*
Phone Number*
Section Break
Patient Guardian/Signature*
I hereby certify that 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 responsible for any balance. I also authorize LEOPOLDO PUGA, MD, INC. or Insurance company to release any information required to process my claims.

Medical Release Form
Release To:*
Address*
Street Address City State ZIP Code
Phone Number*
Fax Number
I hereby authorize this person to furnish the above named individual or company all medical data they must request (including X-ray and Laboratory reports) concerning my illness or injury.*
Indication limitations, if any, of medical information to be released and/or restricitons, if any, of how such information is to be used.
Name*
First Last
Patient's DOB*
MM slash DD slash YYYY
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Requesting*
- Progress Notes
- Labs / X-rays / EKG
- Discharge Summary / H&P
- Billing Information
- Holter
- Thallium / Treadmill
Other:
Section Break
The patient may receive a copy of this authorization if requested. This form expires one year from the date it is signed.
Signature*
I hereby certify that all of the information put forth is correct to the best of my knowledge.
I hereby certify that all of the information put forth is correct to the best of my knowledge.

Patient Consent
Name*
First Last
Birthdate*
MM slash DD slash YYYY
Consent To Medical Services
I as a female patient, under the age of 65, am not currently nursing nor am I pregnant.
Check to Initial
I as a female patient, under the age of 65, am not currently nursing nor am I pregnant.
Consent*

I authorize and direct LEOPOLDO PUGA, MD to perform any Cardiovascular test and/or any other therapeutic procedures that in their judgement will assist in the diagnostic process of my well-being. The nature of the test have been explained to me and I have been advised on the possible risks and consequences. No guarantee has been made as to the result or cure.

I hereby authorize and direct the above physician(s) to provide or cause to provide such additional services for me as they may deem reasonable and necessary.
I authorize and direct LEOPOLDO PUGA, MD to perform any Cardiovascular test and/or any other therapeutic procedures that in their judgement will assist in the diagnostic process of my well-being. The nature of the test have been explained to me and I have been advised on the possible risks and consequences. No guarantee has been made as to the result or cure.

I hereby authorize and direct the above physician(s) to provide or cause to provide such additional services for me as they may deem reasonable and necessary.

Forms