My Heart Spark Patient Visit Check-in Form

Patient Visit CheckIn
Please complete this form ON THE DAY OF and BEFORE your Telehealth visit with us.

Thank you for choosing My Heart Spark. We look forward to working with you and walking with you on this journey to a healthier heart.

If you are feeling unwell, please call 911, visit the closest emergency department, or reach out to urgent care or your primary care provider. Appointment requests and new patient registrations with My Heart Spark P.C. are for non-emergent care only. We are happy to help you once the emergency has passed and you have recovered well.

In order to provide you with the upmost quality care, please complete the form below to the best of your knowledge and ability.

If you have any questions completing this form, please feel free to contact us using the Get In Touch tab in the main menu above.
Basic Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Contact Phone Number Today If Needed:*
Format: (000) 000-0000.
Preferred E-mail Address for Communication with our Team Today If Needed:*
example@example.com
Address Where You Will Be Today For Your Telehealth Appointment*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If anyone will be present, who will be present with you at the Telehealth appointment today? Please provide their full name and the best phone number at which we may reach them today on your behalf if needed.
Weight and Height for BMI

Insurance Information
Yes, I will enter my insurance details below, since I did not get a chance to provide these details previously. I understand that I will be responsible for payment of any services I have not yet paid for, if any portion of the services I receive from My Heart Spark P.C. are not covered or reimbursed by my insurance.Yes, I already provided my insurance details on a previous My Heart Spark P.C. form. I understand that I will be responsible for payment of any services I have not yet paid for, if any portion of the services I receive from My Heart Spark P.C. are not covered or reimbursed by my insurance.No, I do not have insurance details that I would like to provide. I understand that I will be responsible for payment of any services I have not yet paid for, since I do not have insurance to pay for any portion of the services I will receive from My Heart Spark P.C..
Insurance Provider*
Policy Holder Name*
Member ID*
Group Number*

Emergency Contact
Emergency Contact Today If Needed:*

First NameLast Name
Relationship To Patient*
Contact Number Today If Needed*
Format: (000) 000-0000.

Thank you again for choosing My Heart Spark. We look forward to working with you and walking with you on this journey to a healthier heart.

We also request that you upload snapshots or documents of any heart-related clinical notes and results of lab tests and imaging relevant to your heart or blood vessels to be reviewed at the appointment, if you have not yet had a chance to provide them. If the documents are not available at the time of completing this form, please provide them on the Medical Records Upload Form at your earliest convenience.

We will also need you to complete and submit the Authorization to Release Medical Information Form, if you have not yet had the opportunity to do so.

Items needed to complete this form if available:
- Insurance information (if applicable)
- Medical History
- Medical Records: To include the last full office visit note from primary care provider and/or heart doctor (if applicable). Please provide records from any that are applicable. Records should include notes on medical problems/past medical history and heart or blood vessel problems diagnosis (history and treatment information).
- Medical Imaging: To include results of the last 3 echo (ultrasound of the heart) with or without stress test, ECG (squiggly lines looking at electrical activity of the heart), chest X-ray, chest CT, heart MRI, nuclear/sestamibi/myocardial scan stress test, MUGA, brain/head/neck CT or MRI, and any other heart or chest imaging results documents; if possible, please provide from the past few years.
- Lab Test: To include results documenting cholesterol, glucose, liver, kidney, blood cells, and other results checked and provided by primary care clinicians; if possible, please provide from the past few years.
If you have any questions completing the forms, please feel free to contact us at appointments@myheartspark.com.

Please upload a snapshot or document copy of your Medical Records if available: To include the last full office visit note from primary care provider and/or heart doctor (if applicable). Please provide records from any that are applicable. Records should include notes on medical problems/past medical history and heart or blood vessel problems diagnosis (history and treatment information).

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Please upload a snapshot or document copy of your Imaging: To include results of the last 3 echo (ultrasound of the heart) with or without stress test, ECG (squiggly lines looking at electrical activity of the heart), chest X-ray, chest CT, heart MRI, nuclear/sestamibi/myocardial scan stress test, MUGA, brain/head/neck CT or MRI, and any other heart or chest imaging results documents; if possible, please provide from the past few years.

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Please upload a snapshot or document copy of your Lab Tests: To include results documenting cholesterol, glucose, liver function, kidney function, blood cells, and other results checked and provided by primary care clinicians; if possible, please provide from the past few years.

Cancelof

I confirm that all information I have provided is accurate today, and I consent to providing my contact information in order to check in for my scheduled appointment with this clinician today, and I am aware that my information will only be used for these purposes. In the unlikely event that my appointment needs to be rescheduled, My Heart Spark P.C. will contact me 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.
I consent to My Heart Spark P.C. reaching out to testing facilities to obtain my laboratory, imaging, and ECG testing and results to assist with my care. I consent to My Heart Spark P.C. providing and obtaining information, and I am aware that my information will only be used for these purposes. I also consent to My Heart Spark P.C. requesting my laboratory, imaging, and ECG testing and results from the relevant testing facilities, and having the testing facilities personnel provide and obtain my information as well for these purposes. I am aware that the testing facilities personnel may upload my testing and results information via a HIPAA compliant form provided online by My Heart Spark P.C.. 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.
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.
Signature*

Clear
Date*

MonthDayYear
Date

This form will now end after this next message; submit the form, then we will immediately take you to the next crucial form! We can't wait to see you soon. :)
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Patient Visit CheckIn

Basic Information

Insurance Information

Emergency Contact