Lab | Imaging | Patient Education Results Upload for My Heart Spark

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Thank you for assisting with obtaining these tests or patient education sessions for our clients at My Heart Spark P.C.!

To help us provide the utmost quality care for our clients, please send results to us using our secure fax line 414-261-7671, or attach and upload results, reports, and notes, as well as imaging screenshots using this HIPAA compliant form.

If you have any questions or challenges with the form, please feel free to contact us at appointments@myheartspark.com.
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Testing Facility Name* This field is required.
First Name
Last Name
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Name of Testing Facility* This field is required.
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Testing Facility Phone Number* This field is required.
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Testing Facility * This field is required.
example@example.com
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Testing Facility Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
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Algeria
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The Bahamas
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Iran
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Jamaica
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Jersey
Jordan
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Kenya
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North Korea
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Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
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Samoa
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Senegal
Serbia
Seychelles
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Slovenia
Solomon Islands
Somalia
Somaliland
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South Ossetia
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Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Testing Facility Membership Email AddressPlease enter the email associated with your Preventive Cardio-Oncology LLC network membership account, if applicable. www.PrevCardioOnc.com.
example@example.com
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Patient Name* This field is required.
First Name
Last Name
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Patient Date of Birth* This field is required.
Date
Year
Month
Day
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Patient Phone Number* This field is required.
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Patient Email Address* This field is required.Please enter you preferred email for communication with our team.
example@example.com
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Please upload test results along with any relevant information.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Please upload test results along with any relevant information.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
14
Please upload test results along with any relevant information.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
15
Please upload test results along with any relevant information.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Please upload test results along with any relevant information.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Please upload any lab test results and/or imaging results along with any relevant medical history that you wish to discuss during your telehealth appointment.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Please upload any lab test results and/or imaging results along with any relevant medical history that you wish to discuss during your telehealth appointment.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Please upload any lab test results and/or imaging results along with any relevant medical history that you wish to discuss during your telehealth appointment.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
20
Please upload any lab test results and/or imaging results along with any relevant medical history that you wish to discuss during your telehealth appointment.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Terms & Conditions* This field is required.
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Privacy Policy* This field is required.
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Signature Required* This field is required.I consent to providing my contact information and my medical records for clinical review by a My Heart Spark P.C. clinician and other clinic staff at My Heart Spark P.C.. I am aware that my information will only be used for these purposes. I attest that my electronic signature on this form is to have the same legally binding effect as my traditional handwritten signature.
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