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​​​ Thank you for making an appointment with Legacy Heart Center. To better serve you, we ask all new patients to complete the health questionnaire form located below.  Please complete ALL questions to the best of your ability. If a question does not apply to you, please mark "N/A" for Not Applicable.  Items in Red are required.

​Note: If you have any issues completing the online version of this form, use the link below to download the PDF version.

Download PDF Version