ECG Results - Request Form
Use this form to request heart screening results.
IMPORTANT:
Use the same information provided during sign-up
Results will only be sent to the email provided at sign-up
Reason for request
*
Please Select
I am unable to access participant portal
I don't see my ECG result in the participant portal
I am requesting an ECG result performed prior to 2026
Other
Participant First Name
*
Participant Last Name
*
Participant Date of Birth
*
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Date of Screening
*
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Location of Screening
*
Requestor First Name
*
Requestor Last Name
*
Requestor Email
*
example@example.com
Requestor Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Provided at Registration
*
example@example.com
Phone Provided at Registration
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: