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 Hamilton area patients only.

PATIENT INFORMATION


InsuranceType
CC

REASON FOR REFERRAL










CURRENT MEDICATION(S)












Does the patient have Pacemaker or Implanted Cardiac Defibrillator?

Test Requested: