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.

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).

PATIENT INFORMATION


InsuranceType
CC

REASON FOR REFERRAL










CURRENT MEDICATION(S)












Does the patient have Pacemaker or Implanted Cardiac Defibrillator?

Test Requested: