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  • Patient Feedback Form

    Thank you for choosing My Heart Spark P.C.. We are always looking for ways to continue to improve your experience and our service. Please take a few moments to complete this form to provide us with your feedback. Thank you!
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    • RETROSPECTIVE REVIEW CONSENT: I understand that My Heart Spark P.C. (“the Practice”) provides this telehealth visit for me to learn more about protecting my heart. In the future, the Practice may want to look back on all of this work that they have produced to help me. When they look back at everything, they may want to capture summaries of all of the work. These summaries may involve combinations that have my information included in a way that is mixed with everyone else’s and cannot identify me at all. If they look back at this work in this way in the future, they may call this “retrospective research” review. They may present and publish some of the combined and mixed results from this work, in a way that could not identify me. This review would focus on understanding the effectiveness of their services and educational options, so that they can better tailor services/options for the future. Through this review, they may better understand heart health and determine which helpful educational and preventive methods are beneficial in building healthy heart habits. The review committee will understand and respect the privacy of each and every individual. They would present and publish the combined and mixed information from their findings without disclosing my individual personal information in a way that could identify me. By signing below, I consent to my information being used as part of this future review. In the future, I can write them if I ever change my mind and would like my information removed from the combined and mixed results in my research review. I attest that my electronic signature on this form is to have the same legally binding effect as my traditional handwritten signature. I am 18 years of age or older, and I am authorized to sign this form on my own behalf. 
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