PATIENT FORMS   -

Allen & Plano West Clinics

For your convenience, we have placed various patient forms below, in the form of PDF files that you may download at your leisure. Once they have been completed, you can either mail or fax them to this office, or bring them with you to your appointment.

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HeartPlace Allen Clinic Fax #: 844-290-4360

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HeartPlace Plano West Clinic Fax #: 844-290-4363

You will need the Adobe Reader to view and print these documents.

Full Patient Visit Packets​

• New Patient Packet - Dr. Peterman

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• New Patient Packet - Dr. Choudhry/Dr. Sharan

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• New Patient Packet - Dr. Ramanath/Dr. Ammar

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• Established Patient Packet

​​Individual Patient Visit Forms​​​​​

• Patient Demographics Form

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• Patient Privacy Notice (HIPAA)

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• New Patient Questionnaire - Choudhry/Sharan/Peterman

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• New Patient Questionnaire - Ammar/Ramanath

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• Established Patient Questionnaire

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• PAD Questionnaire - Peterman​​

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• Vascular Questionnaire - Ammar/Ramanath

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• Authorization For Release of Medical Records TO HeartPlace

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• Authorization For Release of Medical Records FROM HeartPlace

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• Blood Pressure Log

Patient Testing Instructions​​​​​​​​​​​

• Abdominal Aorta Ultrasound​​​

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• Echocardiogram

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• Nuclear Stress Test - Morning Appointment

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• Nuclear Stress Test - Afternoon Appointment​​​​

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• Stress Echocardiogram​

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• Stress Test​

Patient Procedure Instructions

     POST PROCEDURE​​

• Pacemaker

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• ICD

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• Angioplasty/Stent

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• Open-Heart Surgery

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• Phlebectomy

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• Sclerotherapy​​

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• Endovascular Laser Treatment (EVLT)

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• VenaSeal™ Closure System