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Home
Who We Are
Referral
Get In Touch
Our Newsletter
About Us
Mission
Vision
Educational Material
Sudden Death
Brugada Syndrome
QT Syndrome
Healthcare professionals
News
Language
English
عربي
Referral
Patients
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
Submit Form
