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
Referring Physician
Fax
CPSO/CNO Number
PATIENT INFORMATION
Firstname
Lastname
Gender
M
F
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 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
Submit