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)* ---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)?* ---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.* ---Prefer FlexibleRequire FlexiblePrefer RigidRequire Rigid Please attach CT/MR report