Patient Information
Name: _________________________ Date of Birth: _____________
Medical Record Number: __________ Date: ____________________
Agreement Terms
1. Scope of Services
- Comprehensive cardiovascular care and management
- Regular monitoring of cardiac conditions
- Medication management and adjustments
- Diagnostic testing as medically necessary
- Emergency care coordination
2. Patient Responsibilities
- Attend all scheduled appointments or provide 24-hour notice for cancellations
- Take medications as prescribed
- Report any significant changes in condition promptly
- Maintain accurate records of blood pressure, heart rate, and symptoms as requested
- Inform the practice of any changes in insurance or contact information
3. Provider Responsibilities
- Provide evidence-based cardiac care
- Maintain accurate medical records
- Coordinate with other healthcare providers
- Respond to urgent medical concerns within 24 hours
- Provide clear instructions for medication and lifestyle modifications
4. Emergency Procedures
- Call 911 for life-threatening emergencies
- Contact on-call physician for urgent but non-emergency situations
- After-hours contact number: _________________
5. Medication Management
- Prescriptions will be filled during regular office hours
- Allow 48 hours for prescription refill requests
- Controlled substances require in-person visits
6. Communication Protocol
- Office phone: _______________
- Patient portal: _____________
- Emergency contact: _________
7. Termination of Agreement
Either party may terminate this agreement with written notice.
Signatures
Patient: _________________________ Date: ____________
Provider: ________________________ Date: ____________