Medical Records Upload for My Heart Spark

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Welcome to My Heart Spark!A Message from Dr. Sherry-Ann Brown
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We are looking forward to caring for you at My Heart Spark P.C.!

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 utmost quality care during your appointment, please attach results of lab tests and imaging to be reviewed at your next appointment or to be reviewed in order to electronically send you our comments. You can request copies of your medical records from your health care clinicians. If you haven't yet, please also complete the Authorization to Release Medical Information form so that we can obtain additional information for your medical records if needed.

Items needed to complete this form if available:

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 echocardiograms (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 or CTA or MRA, and any other heart or chest imaging results documents; if possible, please provide from the past few years.

Lab Test Results: 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.

If you have any questions completing the forms, please feel free to contact us using the Get In Touch tab in the main menu above. We also suggest sending a snapshot of the requested items to your healthcare providers and ask them to help with obtaining the required information.
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Name* This field is required.
First Name
Last Name
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Date of Birth* This field is required.
Date
Month
Day
Year
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Phone Number* This field is required.
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Preferred Email* This field is required.Please enter you preferred email for communication with our team.
example@example.com
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Membership EmailPlease enter the email associated with your Heart Beach Garden Signature Program membership account. www.HeartBeachGarden.com.
example@example.com
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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
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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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Select a practitioner* This field is required.
Dr. Sherry-Ann Brown
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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. I am 18 years of age or older, and I am authorized to sign this form on my own behalf.
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Retrospective Review Consent FormI understand that My Heart Spark P.C. (“the Practice”) reviews my clinical information and medical records in order to help care for 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.
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This form will now end after this next message; submit the form, then we will immediately take you to back to our list of forms to check you've got them all! We can't wait to see you soon. :)
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