My Heart Spark - Get Services and Costs

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Welcome to My Heart Spark!A Message from Dr. Sherry-Ann Brown
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Welcome to My Heart Spark P.C.! Fill out this form below to send us a quick question or comment. After submitting this Get In Touch form, you will be brought to a screen where you can start to fill out various forms to establish as a patient with us, so that you can begin or continue as a patient of Dr. Brown. We look forward to caring for you!
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Signature Required* This field is required.I consent to providing my contact and personal information in order to get in touch with Dr. Brown at her new medical practice 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. I am 18 years of age or older, and I am authorized to sign this form on my own behalf.
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Signature Requested for Retrospective Review* This field is required.We provide this method of getting in touch with us for you to have access to us to learn more about protecting your heart. 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 heart health 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 heart health 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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