Patients Form – Hayat Center

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المرضى Form

Patient form

This form is for self-referral

Please confirm the following

I am a Patient

Name

Date of birth

Gender

Male

Female

Phone Number

Email

Condition

Family History of Sudden Cardiac Death

Personal or Family History of Sudden Cardiac Arrest

Inherited Arrhythmias (Brugada Syndrome, LQTS, or CPVT)

Hypertrophic Cardiomyopathy

Arrhythmogenic/Genetic Cardiomyopathy (Including ARVC)

If family history of sudden death, what is your relationship to the deceased?

Parent

Sibling

Son/Daughter

Second degree

Brief description of the incident

Were you seen by a cardiologist before?

Yes

No

If yes, please provide minor details Physician name and hospital

Do you have a file at King Saud University Medical City? *

Yes

No

If yes, what is your MRN or national ID number?

Medical report (if available)

Choose File

النشرة الإخبارية

اشترك في نشرتنا الإخبارية للحصول على تحديثات، أخبار، رؤى أو عروض ترويجية. البريد الإلكتروني

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