My Heart Risk in Cancer Co-Pilot Request Form

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Signature RequiredI consent to providing my contact information in order to schedule an appointment with this provider and aware my information will only be used for these purposes. I'm also aware my appointment request is not guaranteed until confirmed by the provider. Every attempt will be made to honor the selected time, however there may be circumstances in which the provider will have to change the request. In the unlikely event your appointment is rescheduled, the provider will contact you with further information. 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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Retrospective Review Consent FormWe provide this information for you to know an estimate of your heart risk in early breast cancer. In the future, we may want to look back on all of this work that we have produced to help you. When we look back at everything, we may want to capture summaries of all of the work. These summaries may involve combinations that have your information included in a way that is mixed with everyone else’s and cannot identify you at all. If we look back at this work in this way in the future, we may call this “retrospective research” review. We may present and publish some of the combined and mixed results from this work, in a way that could not identify you. This research review would focus on understanding the effects that cancer has on the heart and effectiveness of treatment and educational options, so that we can better tailor our services for the future. Through this research review, we may better understand the effects cancer has on the heart and determine which helpful educational and preventive methods are beneficial in building healthy heart habits. The research review committee will understand and respect the privacy of each and every individual. We would present and publish the combined and mixed information from our findings without disclosing your individual personal information in a way that could identify you. By signing below, you consent to your information being used as part of this future research review. In the future, you can write us if you ever change your mind and would like your information removed from the combined and mixed results in our 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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