Ready to get started? First, let's take care of a few quick items.
Consent & Disclaimers
Please acknowledge the following before we proceed.
Educational & Informational Services *
I understand WhiteGloveMD provides educational and informational clinical analysis. This does NOT establish a physician-patient relationship or replace evaluation by my treating physicians.
I acknowledge that WhiteGloveMD will handle my protected health information (PHI) in accordance with HIPAA regulations and that I may revoke this authorization in writing at any time.
Type your full legal name as your electronic signature.
Medical Records Authorization
This authorization allows WhiteGloveMD to request and receive your medical records for clinical evaluation.
Please fill out the following to the best of your ability. Only fields marked with an asterisk (*) are mandatory. Use the button below to add additional provider locations. This authorization expires one year from the date of signature and may be revoked in writing at any time.
PATIENT INFORMATION
YOUR RELATIONSHIP TO THE PATIENT
Please indicate whether you are the patient or are submitting this request on someone else's behalf.
Current Cardiologist
Cardiac Surgeon (if applicable)
WHERE SHOULD WE GET YOUR RECORDS FROM?
List the hospitals, clinics, and imaging centers where you've been seen for cardiac care. We'll use your signed authorization to request records on your behalf.
RECORDS WILL BE SENT TO
WhiteGloveMD Concierge Patient Support
2831 St. Rose Parkway, Suite 305, Henderson, NV 89052
Phone: (702) 553-0340 · support@whiteglovemd.com
I'm not sure about some of my information
That's okay — our team will verify everything and follow up if needed.
By signing below, you authorize WhiteGloveMD to obtain and use your medical records as described above.
Upload Your Medical Records
If you have medical records, upload them here. Don't worry about sorting or organizing — just give us everything you have. The more information, the more precise your report will be.
✓The note from the surgeon recommending surgery— This tells us exactly what's been proposed and why.
✓Your cardiologist's latest note— Gives us the full clinical picture from your managing physician.
✓Reports from imaging & tests— Echos, cath reports, CTs, MRIs, stress tests — all of it.
✓Lab results— Recent bloodwork helps complete the risk assessment.
Drop files here or click to browse
PDF, DICOM, JPG, PNG, DOC (max 50MB per file)
Do you have imaging CDs, disks, or DICOM files?
If you have physical CDs or disks with imaging studies, you can upload DICOM files directly above, or mail them to: WhiteGloveMD, 2831 St. Rose Parkway, Suite 305, Henderson, NV 89052
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Your records are secure
Encrypted in transit (TLS 1.3) and at rest (AES-256). HIPAA-compliant with full BAA coverage.
Before we begin your review
We cannot begin your review until we're confident we have all the notes, labs, and imaging you want us to consider. Please select one of the following:
I've given you everything.
Everything I have has been uploaded. I have no additional records to provide.
I've uploaded what I have, but there's more out there.
I've listed where to find the rest on my medical authorization form.
I don't have any records, but I've told you where to find them.
Use my signed authorization to request records from the facilities I listed.
Not sure?
No worries. Our team is here to help you figure out what records you need.