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Available Forms

BRMG ADVANCED DIRECTIVE NOTIFICATION FORM

Blue Ridge Cardiology & Internal Medicine

Advanced Directive Notification Form

 
If yes please list name and contact information below

I have talked with my family and my doctor about the care I want. If I am unable to speak for myself, please contact:

 
(Name) (Phone #) (Relationship to Patient)
(Name) (Phone #) (Relationship to Patient)
(Name) (Phone #) (Relationship to Patient)
 
 
Electronic Signature
Date of Birth
* Required field