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Holter Monitoring
Home Sleep Apnea Test
Providers
Holter Monitoring
Home Sleep Apnea Test
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Patients
Holter Monitoring
Home Sleep Apnea Test
Providers
Holter Monitoring
Home Sleep Apnea Test
About us
Collaboration & Research
Our Technology
Contact us
Refer a Patient
Provider Login-In
Order a test today.
Home Holter Test Referral
Home Sleep Apnea Test Referral
At-Home Sleep Apnea Test Referral
Download Physician's Referral PDF
Download Dentist's Referral PDF
I am a:*
Physician
Dentist
Test type:*
Home Sleep Test
Home Sleep Test followed by consultation (if necessary)
Has the clinic collected payment?*
If the clinic has received payment, m-Health invoices the clinic monthly; otherwise, m-Health collects payment directly from the patient.
Yes
No
Provider Information
Referring Provider's Name
*
Referring Provider Number (Ex: CPSO, CNO, RCDSO)
*
OHIP Billing Number (if applicable)
How would you like to receive results?*
Fax
Email
Patient Information
First Name
*
Middle Name
Last Name
*
Gender
*
Select
M
F
Home Address
*
Unvalidated
Validated
ValidationOverride
Address not found. Do you still want to use it?
Address
*
Unit
City
*
Province
*
ON
AB
BC
MB
NB
NL
NT
NS
NT
PE
QC
SK
YT
Postal Code
*
Date of Birth
*
Phone Number
*
Mobile
Home
Other
Email
Health Card Number
*
Version Code
*
Copy Results To:
Full Name
Phone
Email Address or Fax
Reason for Referral*
Snoring
Central Sleep Apnea R/O
Teeth grinding/ clenching
Pauses or choking while asleep
Restless sleep
Obstructive Sleep Apnea R/O
Pauses or choking while asleep
Daytime fatigue
Obesity
Restless leg/ limb syndrome
Insomnia
Syncope
Other
Additional Notes:
I have explained to the patient that the home sleep apnea test is not covered by OHIP and is a private-pay test.
Please note: We must be in contact with your patient to confirm shipping address & collect payment prior to mailing the device.
By submitting this form, I confirm that the information provided is accurate and I accept responsibility for verifying its accuracy and completeness. The patient has also provided consent for their test and the transmission of the information above.
Submit