Professionals Form – Hayat Center

Professional Form

Physician Referral Form

Please fill in the details of the concerned patient. If the referral for a whole family, kindly fill the form once, and include the contact details of the main family member who will handle communication with the center team member

Please confirm the following

i am a Physician

Patient Name

Date of birth

Gender

Male

Female

Phone Number

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)

Brief details about reason for referral

Referring Physician Name

Referring Physician Phone Number

Referring Physician Email

Referring Physician Hospital

Kindly attach medical reports, including all relevant investigations (ECG, echo, cardiac MRI, genetic testing, etc..)

Choose File