⚠️TEST CLINIC — Maria Lahti Cardiology — Demo Data Only⚠️

Patient Forms

Intake forms, consents, and authorizations

Completed

11

Pending

5

Expired

2

Form Name

Type

Patient

Status

Assigned

Completed

Expires

New Patient Intake Form

Intake

Carlos Reyes

Completed

Mar 18, 2026

Mar 18, 2026

Mar 18, 2027

New Patient Intake Form

Completed

Carlos ReyesIntakeMar 18, 2026

HIPAA Acknowledgment

Consent

Carlos Reyes

Completed

Mar 18, 2026

Mar 18, 2026

Mar 18, 2027

HIPAA Acknowledgment

Completed

Carlos ReyesConsentMar 18, 2026

Consent for Treatment

Consent

Carlos Reyes

Completed

Mar 18, 2026

Mar 18, 2026

Mar 18, 2027

Consent for Treatment

Completed

Carlos ReyesConsentMar 18, 2026

Financial Responsibility Agreement

Financial

Carlos Reyes

Completed

Mar 18, 2026

Mar 18, 2026

Mar 18, 2027

Financial Responsibility Agreement

Completed

Carlos ReyesFinancialMar 18, 2026

TAVR Procedure Consent

Consent

Eleanor Whitfield

Pending

Mar 19, 2026

--

Apr 2, 2026

TAVR Procedure Consent

Pending

Eleanor WhitfieldConsentMar 19, 2026

Anesthesia Consent

Consent

Eleanor Whitfield

Pending

Mar 19, 2026

--

Apr 2, 2026

Anesthesia Consent

Pending

Eleanor WhitfieldConsentMar 19, 2026

Blood Transfusion Consent

Consent

Eleanor Whitfield

Pending

Mar 19, 2026

--

Apr 2, 2026

Blood Transfusion Consent

Pending

Eleanor WhitfieldConsentMar 19, 2026

Cardiac Rehab Intake

Intake

Thomas Williams

Pending

Mar 17, 2026

--

Apr 17, 2026

Cardiac Rehab Intake

Pending

Thomas WilliamsIntakeMar 17, 2026

ICD Implant Consent

Consent

Mildred Brooks

Completed

Mar 1, 2026

Mar 1, 2026

Mar 1, 2027

ICD Implant Consent

Completed

Mildred BrooksConsentMar 1, 2026

Patient Health Questionnaire (PHQ-9)

Screening

Roberto Espinoza

Completed

Mar 7, 2026

Mar 7, 2026

Sep 7, 2026

Patient Health Questionnaire (PHQ-9)

Completed

Roberto EspinozaScreeningMar 7, 2026

Annual HIPAA Acknowledgment

Consent

James Morrison

Completed

Jan 15, 2026

Jan 15, 2026

Jan 15, 2027

Annual HIPAA Acknowledgment

Completed

James MorrisonConsentJan 15, 2026

Annual HIPAA Acknowledgment

Consent

William Jackson

Completed

Jan 5, 2026

Jan 5, 2026

Jan 5, 2027

Annual HIPAA Acknowledgment

Completed

William JacksonConsentJan 5, 2026

New Patient Intake Form

Intake

Sandra Gupta

Completed

Mar 13, 2026

Mar 13, 2026

Mar 13, 2027

New Patient Intake Form

Completed

Sandra GuptaIntakeMar 13, 2026

Catheter Ablation Consent

Consent

Dorothy Hayes

Pending

Mar 17, 2026

--

Apr 17, 2026

Catheter Ablation Consent

Pending

Dorothy HayesConsentMar 17, 2026

Annual HIPAA Acknowledgment

Consent

Dorothy Hayes

Expired

Jan 10, 2025

Jan 10, 2025

Jan 10, 2026

Annual HIPAA Acknowledgment

Expired

Dorothy HayesConsentJan 10, 2025

Annual HIPAA Acknowledgment

Consent

Richard Petrov

Expired

Feb 15, 2025

Feb 15, 2025

Feb 15, 2026

Annual HIPAA Acknowledgment

Expired

Richard PetrovConsentFeb 15, 2025

Medication Authorization

Authorization

Edward Kowalski

Completed

Mar 10, 2026

Mar 10, 2026

Sep 10, 2026

Medication Authorization

Completed

Edward KowalskiAuthorizationMar 10, 2026

Release of Medical Records

Authorization

Eleanor Whitfield

Completed

Mar 14, 2026

Mar 14, 2026

Jun 14, 2026

Release of Medical Records

Completed

Eleanor WhitfieldAuthorizationMar 14, 2026

Showing 18 forms