My Heart Spark - Patient Phone Call Report Form

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My Heart Spark Poem
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Welcome to My Heart Spark P.C.! Fill out this form below to send us a detailed report of your phone call with the patient. Please include how and why the call was originated, whether you called or the patient called and why, the topic of the phone call, symptoms, concerning findings, the immediate plan discussed, the plan for follow-up, and how the patient will be seen soon by Dr. Brown.

After submitting this form, you will be taken to the SimplePractice EHR login page in case you need to do anything else there.

Thank you for caring for our patients, who need you!
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Name of Person Submitting This Form* This field is required.
First Name
Last Name
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Today's Date* This field is required.
Date
Year
Month
Day
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Patient Name* This field is required.
First Name
Last Name
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Patient Date of Birth
Date
Year
Month
Day
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Patient Phone Number* This field is required.
Area Code
Phone Number
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Patient Email
example@example.com
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Patient Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
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
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
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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Today I Am Feeling (Person Filling Out This Form)How are you doing today?
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Please type detailed report of patient phone call* This field is required.Fill out this form below to send us a detailed report of your phone call with the patient. Please include how and why the call was originated, whether you called or the patient called and why, the topic of the phone call, symptoms, concerning findings, the immediate plan discussed, the plan for follow-up, and how the patient will be seen soon by Dr. Brown.
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How was the call with the patient pursued?* This field is required.
From directly within Reach UC
Via Doximity
Via Zoom Health
Via Simple Practice
Via Epic
On my celphone (not using any of the other options listed here) - which we try not to do due to HIPAA Compliance
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Tell us of any questions or comments for Dr. BrownWe will love to hear from you!
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Signature Required* This field is required.I consent to providing my contact and personal information in order to provide this patient phone call report for 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 ReviewWe provide this method of logging patient phone call reports to help us learn more about using such methods to support patients in protecting their heart. In the future, we may want to look back on all of this work that we have produced has been helpful. 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 identify you if only a few people are logging these patient phone all reports. This research review would focus on understanding the effectiveness of these methods in our efforts to help preserve heart health, so that we can better tailor our services for the future. Through this research review, we may better understand heart health and determine which 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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