Welcome to My Heart Spark P.C.! We are thrilled to have you.
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 complete the forms below to the best of your knowledge and ability.
We also request that you upload any new heart-related clinical notes and results of lab tests and imaging relevant to your heart or blood vessels to be reviewed at the appointment, as well as any results or notes you were not able to upload prior to your first visit with us. You can request a copy from your health care clinician. If the documents are not available at the time of completing this form, please provide them on the Medical Records Upload Form prior to your scheduled appointment.
We will also need you to complete and submit both the New Patient Registration Form and the Authorization to Release Medical Information Form prior to your telehealth appointment.
Your appointment will be with one of our clinicians in our sister company My Heart Spark P.C., and you can select which clinician you would like to see.
Required items needed to complete this Telehealth Visit Request Form:
- Insurance information (if applicable)
- Medical History
- 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 echo (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, 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, kidney, 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 about completing any of 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.