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 Hamilton area patients only.
14 Day Holter (PocketECG)
72 Hour Holter
Health Card Number
REASON FOR REFERRAL
Shortness of Breath
Does the patient have Pacemaker or Implanted Cardiac Defibrillator?
Implanted Cardiac Defibrillator
Repeat if inconclusive (Test to be done 1 month after)
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