Intake Form

SmartHeart^® Member Eligibility Form

Administering medical services and performing a 12-lead ECG exam requires the following information.

First name

Last name

Phone number

Birthday

Month

Day

Year

Sex Assigned at Birth

Member State of Residence

* I agree to the SmartHeart Terms of Use, Privacy Policy, and the medical group’s Telehealth Informed Consent, Notice of Privacy Practices, and Self-Payment of Medical Services.