Heart-in-Hand Pledge Intake Form

Case Information

Requesting Physician*

Title

Email*

Proposed use of requested model*

Detailed diagnosis of patient*

Type of images to be provided (MR/CT)*
—Please choose an option—MRCT

Date images taken*

Anatomical area(s) of interest*

When is this patient scheduled for surgery?*

Model Information

Would you like a blood-volume model (depicting internal structures using contrast in blood) or shell model (external walls)?*
—Please choose an option—Blood-Volume ModelShell Model

Do you require/prefer a flexible/rigid model? Please be aware that flexible models require more time to print, are more vulnerable in transport, and cost more money. But for certain applications/lesions, they are the best option.*
—Please choose an option—Prefer FlexibleRequire FlexiblePrefer RigidRequire Rigid

Please attach CT/MR report