# Carda Health Enrollment Form

Welcome! To ensure we give you the best possible experience, we need to quickly collect some information from you including your contact information and your consent for us to request relevant medical information from your physician.

If you have any questions please call our helpline at (323)-894-9294. We are always on standby, happy to help. This form will take 3-5 minutes to complete.

## Your Contact Information

- **Name***  
  First Name Last Name
- **Phone Number***  
  Please enter your mobile phone number or the best number to reach you at. Format: (000) 000-0000.
- **Preferred Email***  
  example: test_email@gmail.com

## Address for your (free!) Carda Care Package

Please enter your address below, this way we can make sure we get you our Carda Care Package ASAP!

- **Home Address***  
  Street Address  
  Street Address Line 2  
  City State / Province  
  Postal / Zip Code

## Insurance Information

- **Plan Name***
- **Policy ID / Member ID***
- **Supplementary Insurance (if applicable)**  
  Please enter your supplementary medicare plan above if you have one
- **Policy ID / Member ID**

## Medical Questionnaire

- Have you ever experienced or been diagnosed with (check all that apply):  
  Heart attack, Sudden cardiac arrest, Heart failure, Stroke, Arrhythmia, Stable angina, Heart valve complications, COPD or any lung disease

- Have you ever undergone a cardiac surgery or procedure:  
  Yes / No

- If you answered yes to the above question, please provide a summary of what surgeries or procedures you have had done:

- Do you have any of the following (check all that apply):  
  Chest pain, Shortness of breath, High blood pressure, High cholesterol, Diabetes or pre-diabetes

- Please list any medications or supplements you are currently taking:

## Medical Records (this helps us speed up your care!)

To provide you with the best care possible we need to request some of your medical records. Please enter the contact information of your doctor. If you have this information handy it is helpful for us to collect it.

- **Cardiologist Name (Ideal - if not available, please provide PCP)***  
  First Name Last Name
- **Phone/Fax***  
  Please enter a valid phone number. Format: (000) 000-0000.

## Release Consent

I authorize the release of my pertinent medical records to Carda Health. I understand these records will only be used to aid in my treatment, and will not be released to any person or agency without my authorization:  
  History & Physical, Medication List, Imaging/Diagnostic reports, Emergency Room Record, Operative Reports, Consultation Report, All of the above

- **Name***  
  First Name Last Name
- **Date of Birth***  
  Month - Day - Year

- **Signature***

## Consent to Participate

### Consent to Participate

**1. Purpose and Explanation of Procedure**  
The purpose of this consent is to inform you of the following:  1. How Carda Health and the treating Exercise Physiologist will use and disclose the information you share, 2. What other entities Carda Health might share information with, and 3. the risks associated with this telerehabilitation (Telerehab) encounter.

In order to improve my physical capacity and generally aid in my medical treatment for heart disease, I hereby consent to enter a virtual cardiac rehabilitation program that will include telemedicine visits, cardiovascular monitoring, physical exercise, dietary counseling, smoking cessation, stress reduction, and health education activities. The levels of exercise that I will perform will be based on the condition of my heart and circulation as determined by my care team. Professionally trained clinical personnel will provide leadership to direct my activities and may monitor my heart rate and blood pressure to be certain that I am exercising at the prescribed level. I understand that I am expected to attend every session and to follow staff instructions with regard to any medications that may have been prescribed, exercise, diet, stress management, and smoking cessation.

In the course of my participation in exercise, I will be asked to complete the activities unless such symptoms as fatigue, shortness of breath, chest discomfort, or similar occurrences appear. At that point, I have been advised that it is my complete right to stop exercise and that it is my obligation to inform the program personnel of my symptoms.

**2. Risks**  
It is my understanding that there exists the possibility during exercise of adverse changes including abnormal blood pressure; fainting; disorders of heart rhythm; and very rare instances of heart attack, stroke, or even death. Every effort will be made to minimize these occurrences through risk stratification, proper staff assessment of my condition before each exercise session, staff supervision during exercise, and my own careful control of exercise effort.

**3. Benefits to Be Expected**  
I understand that this medical treatment may or may not benefit my health status or physical fitness. Generally, participation will help determine what recreational and occupational activities I can safely and comfortably perform at home or on my own. Many individuals in such programs also show improvements in their capacity for physical work.

**4. Confidentiality and Use of Information**  
I understand that Carda Health may collect, use and disclose my personal information and my personal health information for purposes of;  
  • Assessing, treating or providing other health related services by using virtual internet or telephone communication strategies (TeleRehab).
  • Providing treatment outcomes and identifying future rehab services that may be provided.
  • Enabling an insurer or funder to determine any potential funding coverage further to my claim.
  • Seeking payment for the services I received.

**5. Acknowledgement**  
I acknowledge that I have read this page in its entirety. I further understand that there are remote risks other than those previously described that may be associated with this program. Despite the fact that a complete accounting of all remote risks is not entirely possible, I am satisfied with the review of these risks that was provided to me, and it is still my desire to participate.