FORMS
​
-
Get Services and Costs Form: Please use this form to request a list of our services and costs tailored to your needs. Please also then go ahead and complete the additional forms below to get ready for your visit. We are thrilled to have you!
-
First Telehealth Appointment Request Form: Please use this form to request your first telehealth visit with one of our expert clinicians.
-
My Heart Spark Virtual Guide Request Form: Please sign up for a pre-visit and post-visit with our My Heart Spark Virtual Guide to walk you through the process, to prepare you for your appointments and also your escapades into virtual reality for physical activity and community.
-
Follow-up Telehealth Appointment Request Form: Please use this form to request your future telehealth visits with our expert clinicians; you can set up as many of these in advance as you would like, even without waiting for your first appointment.
-
New Patient Registration Form: Please complete the form in its entirety prior to your telehealth appointment with us.
-
Authorization to Release Medical Information Form: Please complete the form in its entirety prior to your telehealth appointment with us.
-
Medical Records Upload: Please attach medical records including clinical notes and results of lab tests, ECGs, and other heart imaging to be reviewed at the appointment; you can request copies from your health care clinicians.
-
My Heart Spark Concierge Community Join Form: Please complete this form to join our concierge signature program community Heart Beach Garden.
-
My Heart Spark Community Participant Consent: Please complete this form after joining our concierge signature program community Heart Beach Garden.
​
ADDITIONAL Forms for Completion BEFORE Your Appointment With Us If You Have Had Early Breast Cancer:
1. My Heart Risk in Cancer Assessment: Please complete this form to obtain your personal customized heart risk in cancer estimate to help determine your risk of having heart problems after early breast cancer diagnosis or treatment.
2. My Heart Risk 1.0 Co-Pilot Appointment Request Form: Please complete this form to request an appointment with our Virtual Co-Pilot to walk you through the risk estimator tool, without providing medical counseling or advice.
Form for Completion AFTER Your Appointment With Us:
* Patient Feedback Form: Please complete this form to help us better serve you.
​
Forms You Will Also Complete Around the Time of Your Appointment With Us:
​
Forms for Our Staff or Collaborators to Complete for You:
* Patient Phone Call Report Form
* Patient Medical Records Summary
* Telehealth Patient Intake Form (Physician/NP Internal Use)
* My Heart Spark Labs, Imaging, and ECG Request Form
* Lab | Imaging | ECG Results Upload for My Heart Spark
​
​