JHS | Sports EKG Appointment Registration

Sports EKG Appointment Registration

Appointment Information

Location

Dates

Time Slot

Patient Information

Is the patient 18 years old or older?

First Name

Middle Name

Last Name

Date of Birth

Sex on Government ID

Primary Phone Number

Alternate Phone Number

Student ID

Which school do you play sports for?

Patient's Home Address Information

Street

Suite/Apartment

City

State

Zip Code

Parent/Guardian

First Name

Last Name

Relationship

Date of Birth

Phone Number

Sex on Government ID

Emergency Contact

Emergency Contact Same as Parent/Guardian

First Name

Last Name

Relationship to Patient

Phone Number

Consents

Please click on the icons below to read and sign the required consent forms.

1- HIE Consent Form C-613E

2- General Consent and Conditions for Treatment-Outpatient C-613OT

Documents

Please upload a photo of the Parent/Guardian's Driver License, ID Card, Passport, or other Government Photo ID Card.

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Photo ID Uploaded Successfully

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I do hereby consent to participation in the EKG screen on behalf or that of my minor child.

Parent/Guardian Full Name

Date

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