My Heart Spark Virtual Guide Determination Form

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Welcome to My Heart Spark!A Message from Dr. Sherry-Ann Brown
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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
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Email* This field is required.
example@example.com
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Address
Street Address
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Afghanistan
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Mayotte
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Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
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New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
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Northern Mariana
Norway
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Paraguay
Peru
Philippines
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Poland
Portugal
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Qatar
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Romania
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Saint Helena
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eSwatini
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Other
Country
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Please let us know your state of residence* This field is required.Thank you!
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How would you like to speak with a Virtual Guide?* This field is required.
Video
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Select an appointment type* This field is required.
Visit with Virtual Guide for My Heart Spark
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Which session type did you sign up for?* This field is required.Thank you for being with us!
Cardiology Consultation - with our physician Dr. Sherry-Ann Brown
Clinician Visit Risk Discussion - with our physician Dr. Sherry-Ann Brown
Individual Education Session - with our physician, nurse, or medical assistant
Group Education Session - with our physician, nurse, or medical assistant
External Medical Record Retrieval Review - with our physician, nurse, or medical assistant
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Thank you for setting up an education session with us. We look forward to having you. Please check out the resources at this link below to prepare you for your session with us. See you soon!

My Heart Risk Creative Learning
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SESSION APPOINTMENT

Your session appointment will be with one of our clinicians in our sister company My Heart Spark P.C., in collaboration with My Heart Risk.

You will need both a 1) PREVISIT REVIEW with a My Heart Spark Virtual Guide to walk you through the process, and a 2) POSTVISIT CARE PLAN WRAPUP Q&A with a My Heart Spark Virtual Guide to walk you through the care plan customized for you and answer your questions after the clinic visit, to help you to thrive in community and plan your future appointments.
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PREVISIT REVIEW

Please also sign up for a pre-visit review with a My Heart Spark Virtual Guide to walk you through the process, to prepare you for your appointments and also your escapades into virtual reality for physical activity and community.
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Which PRE-VISIT Review Are You Signing Up For?* This field is required.Thank you for being with us!
5-minutes pre-visit review ($0): Learning more about our boutique medical practice with emotional and social support and what you will experience in your session and beyond.
10-minutes pre-visit review ($25): Learning more about our medical practice with emotional and social support and what you will experience in your session and beyond; Learning more about Dr. Brown and why we offer you this service.
15-minute pre-visit review ($50): Learning more about our medical practice with emotional and social support and what you will experience in your session and beyond; Learning more about Dr. Brown and why we offer you this service; Having space, a time, and place to cry, talk, explain, ask questions, be comforted, and chat live and directly in front of you face to face on the screen with someone whose family has been there too - our anchor medical assistant Monique McGahee, grab some tissues and maybe some wine, get ready to connect! (If you're thinking 15 minutes won't be enough for this, just sign up for as many pre-visit and post-visit sessions as you would like to have with Monique! We love to do our jobs and our job is to be here for you.)
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POSTVISIT CARE PLAN WRAPUP Q&A

Don’t forget to also sign up for a post-visit care plan review with a My Heart Spark Virtual Guide to walk you through thr care plan customized for you and answer your questions after the clinic visit, to help you to thrive in community and plan your future appointments.
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Which POST-VISIT Review Are You Signing Up For?* This field is required.Thank you for being with us!
5-minutes post-visit review ($0): Let Monique walk you through some of the new information you got at the appointment.
10-minutes post-visit review ($25): Let Monique walk you through some of the new information you got at the appointment. It's a lot. Let Monique give you tips on how to sort through it all and plan for the future. There's a lot to learn about your heart risk in cancer. You may have more questions than answers, and Monique can help us help you walk through them in community.
15-minute post-visit review ($50): Let Monique walk you through some of the new information you got at the appointment. It's a lot. Let Monique give you tips on how to sort through it all and plan for the future. There's a lot to learn about your heart risk in cancer. You may have more questions than answers, and Monique can help us help you walk through them in community.
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Virtual Guide Video Visit Payment* This field is required.Please click on the blue and white + (plus sign) for the options you prefer for BOTH Pre-Visit Review AND Post-Visit Review. Thank you! We look forward to seeing you. :)
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ORDER SUMMARY
Total costUSD
5-minutes PRE-visit review ($0): Learning more about our boutique medical practice with emotional and social support and what you will experience in your session and beyond.Complementary 5-minutes PRE-visit review ($0)
$FreeEdit
Back
Quantity
5-minutes POST-visit review ($0): Let Monique walk you through some of the new information you got at the appointment.Complementary 5-minutes POST-visit review ($0)
$FreeEdit
Back
Quantity
10-minutes PRE-visit review ($25): Learning more about our medical practice with emotional and social support and what you will experience in your session and beyond; Learning more about Dr. Brown and why we offer you this service.10-minutes PRE-visit review ($25) plus ~5% service charge
$27.00Edit
Back
Quantity
10-minutes POST-visit review ($25): Let Monique walk you through some of the new information you got at the appointment. It's a lot. Let Monique give you tips on how to sort through it all and plan for the future. There's a lot to learn about your heart risk in cancer. You may have more questions than answers, and Monique can help us help you walk through them in community.10-minutes POST-visit review ($25) plus ~5% service charge
$27.00Edit
Back
Quantity
15-minute PRE-visit review ($50): Learning more about our medical practice with emotional and social support and what you will experience in your session and beyond; Learning more about Dr. Brown and why we offer you this service; Having space, a time, and place to cry, talk, explain, ask questions, be comforted, and chat live and directly in front of you face to face on the screen with someone whose family has been there too - our anchor medical assistant Monique McGahee, grab some tissues and maybe some wine, get ready to connect! (If you're thinking 15 minutes won't be enough for this, just sign up for as many pre-visit and post-visit sessions as you would like to have with Monique! We love to do our jobs and our job is to be here for you.)15-minute PRE-visit review ($50) plus ~5% service charge
$53.00Edit
Back
Quantity
15-minute POST-visit review ($50): Let Monique walk you through some of the new information you got at the appointment. It's a lot. Let Monique give you tips on how to sort through it all and plan for the future. There's a lot to learn about your heart risk in cancer. You may have more questions than answers, and Monique can help us help you walk through them in community. The comfort you can gain from being with someone whose family has been there too is unfathomable. Process with Monique all that you have learned. Cry, talk, explain, ask questions, and be comforted. Then let's get ready to play together with others around the country who are going through this too!15-minute POST-visit review ($50) plus ~5% service charge
$53.00Edit
Back
Quantity
Total cost $0.00
Credit Card
First Name
Last Name
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Did You Click On TWO SEPARATE Blue and White Crosses To Select Payment Options for Both a PRE-VISIT *and* a POST-VISIT Virtual Guide Session?* This field is required.Thank you! We look forward to serving you. :)
Yes, I will proceed to the next screen
No, I will go back to the previous screen and select a POST-VISIT Virtual Guide Session as well
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Select a Virtual Guide* This field is required.
Monique McGahee
Melinda Michaels
Marissa Aldridge
Any
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Select a Virtual Guide Appointment Time that is JUST BEFORE Your Clinic VisitWe will try to honor this date, including today, with at least one hour's notice!
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Select a Virtual Guide Appointment Time that is JUST BEFORE Your Clinic VisitWe will try to honor this date, including today, with at least one hour's notice!
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Select a Virtual Guide Appointment Time that is JUST BEFORE Your Clinic VisitWe will try to honor this date, including today, with at least one hour's notice!
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Select a Virtual Guide Appointment Time that is RIGHT AFTER Your Clinic VisitWe will try to honor this date, including today, with at least one hour's notice!
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Select a Virtual Guide Appointment Time that is RIGHT AFTER Your Clinic VisitWe will try to honor this date, including today, with at least one hour's notice!
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Select a Virtual Guide Appointment Time that is RIGHT AFTER Your Clinic VisitWe will try to honor this date, including today, with at least one hour's notice!
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What additional timeframes between 6 pm and 9 pm EST work for you on the date you have selected, including timeframes outside of the availability times you see above?* This field is required.Be sure to factor at least an hour for you to complete our forms and previsit work before your session.
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What additional timeframes between 9 am and 9 pm EST work for you on the date you have selected, including timeframes outside of the availability times you see above?* This field is required.Be sure to factor at least an hour for you to complete our forms and previsit work before your session.
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Terms of Service* This field is required.
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Privacy Policy* This field is required.
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Signature Required for Visit with Virtual Guide* This field is required.I consent to providing my contact information in order to schedule an appointment with this provider and aware my information will only be used for these purposes. I'm also aware my appointment request is not guaranteed until confirmed by the provider. Every attempt will be made to honor the selected time, however there may be circumstances in which the provider will have to change the request. In the unlikely event your appointment is rescheduled, the provider will contact you 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.
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Signature Requested for Retrospective Review ConsentWe provide this visit for you to learn more about your heart health and your heart spark. 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 the effectiveness of treatment and educational options, so that we can better tailor our services for the future. Through this research review, we may better determine which helpful educational and preventive methods are beneficial in building heart healthy 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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This form will now end after this next message; submit the form, then we will immediately take you to a list of all the helpful forms! We can't wait to see you soon. :)
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Company Email To Receive Completed Form PDF
appointments@myheartspark.com
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appointments@myheartspark.com
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