New Patient Intake

Required Information

Note: This is the first step in gathering new patient intake information with z [PAUSED] - James Kim Cardiology and it helps our staff to schedule your visit. More intake information will be required subsequently, and we appreciate your understanding.

First Name *

Last Name *

Phone *

Date of birth *

Have you seen another physician for the condition you are contacting us about in the past 12 months? *

Yes

If so, what is the name of the Physician you saw?

Do we have permission to contact this Physician?

Yes

Insurance company name *

Insurance plan ID

Insurance group number

By providing my phone number, I agree to receive text messages from z [PAUSED] - James Kim Cardiology and understand that I can opt out by replying PAUSE.