Online Referral Form

Please note: Due to extremely high parcel volumes with Canada Post and other delivery services, we are experiencing delays in the delivery of our Holter Monitors. We are communicating this to your patients.

Please select the type of test

72 Hour Holter referrals are available for patients in Southern Ontario only (if your patient falls outside of the catchment area we will be in contact with your clinic for alternate test options).

Referring Physician

Fax

CPSO/CNO Number

PATIENT INFORMATION

Firstname

Middlename

Lastname

Gender

Address

Unit

City

Province

Postal Code

DOB

Phone

InsuranceType

Public insurance

Private insurance

Cash

Health Card Number

Version Code

CC

Name

Fax

REASON FOR REFERRAL

A-Fib/Flutter R/O

Chest Pain

Dizziness

Palpitations

Shortness of Breath

Syncope

TIA/Stroke

Other

CURRENT MEDICATION(S)

ASA

ACE Inhibitor

ARB

Beta Blocker

Statin

Anti-Coagulant

Oral anticoagulant

None specified

Other

None

Does the patient have Pacemaker or Implanted Cardiac Defibrillator?

Pacemaker

Implanted Cardiac Defibrillator

Test Requested:

2 Weeks

Repeat if inconclusive (Test to be done 1 month after)

Notes

If you wish to receive a confirmation email that the referral was submitted successfully, please enter the email you want the confirmation to be sent to:

I wish to have the results securely emailed to the email address entered above.

I acknowledge that I am a registered HCP.

By referring the above patient for the m-CARDS service, I acknowledge I have completed the patient education and technical set-up as outlined here

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Hamilton, ON L8P 4M4
Phone: 1-888-636-0186