Guard Your Heart
Cardi V CPL
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CPL
Quest
Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Phone Number
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Please enter a valid phone number.
Email
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example@example.com
Demograhic Information
Birth Gender
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Male
Female
Race/Ethnicity
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Please Select
Black or African American
White
Hispanic or Latino
Asian or Asian American
American Indian or Alaska Native
Native Hawaiian or OPI
Other
Annual Household Income Range
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$0-$15,000
$45,001-$60,000
$15,001-$30,000
$60k+
$30,001-$45,000
Current Insurance Coverage? Just Data. The test is free.
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Private
Medicare
Insured through employer
No coverage
Medicaid
Military
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health Information
Have you ever been diagnosed with any of the following?
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Cancer
High blood pressure
Heart Problems
Bad Cholesterol
Diabetes/Sugar
Liver Disease
Mental Health Disorders (e.g., bipolar, depression, anxiety, etc.)
Kidney Disease
Obesity
Stress
None of the above
Have you ever seen/been referred to a cardiologist/heart doctor since being diagnosed with any of the above conditions?
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Yes
No
Date Today
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Month
-
Day
Year
Date
BHA Waiver & Consent Form
Procedure Description: I understand that as part of the screening process, a small sample of blood will be collected either by venipuncture or finger prick.Risks Acknowledgment: I am aware of the associated risks, which include but are not limited to: BleedingVessel injury Bruising Infection Disclaimer of Relationship: I acknowledge that participation does not create a patient/doctor relationship with BHA, its affiliates, or any healthcare providers involved. Emergency Authorization: In case of an emergency, I authorize BHA, its affiliates, or healthcare providers to arrange for necessary medical treatment. I agree to hold harmless all parties involved in the administration of such emergency care. I understand that I am responsible for any medical expenses related to the emergency treatments provided.Minor Consent: For participants under the age of 18, a signature from a parent or guardian is required. Communication Consent: By signing this form, I consent to receive periodic newsletters from BHA. I understand that these communications are part of my engagement with BHA and I can opt-out at any time.By typing my name below, I provide my consent for BHA to perform the screening as described above and waive any liability against BHA and their partners for the conduct of the screening.
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I accept the Terms and Conditions
Data is essential for keeping our bus operational and plays a critical role in helping us potentially save lives from heart attacks or strokes. We would like your permission to use your data, ensuring that no identifiable information will be included, for our white paper, research or policy/laws. Rest assured, we will never sell your personal information. Is it okay for us to use your data in this way?
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Yes, you have permission to share my information
No, I'm not interested in sharing my information with anyone
Would you like to become a member BHA's "Heart Guard Champion" advocacy program? This program is dedicated to the principles of justice, righteousness, and equity. Our mission is to combat injustice, inequity, and unrighteousness within the healthcare system and beyond. We invite you to join us in our fight by engaging in policy reform, addressing systemic issues, and raising your voice for our patient community. Together, we can create a more just and equitable world. Join Heart Guard today and be a part of the change!
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Sign me up!
Not interested at this time
(Skip if N/A)Spouse/Minor's Name
First Name
Last Name
Spouse/Minor Birthday
(Skip if N/A)Spouse/ Minor's email address (must be different from above email)
example@example.com
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