Referrals.m-healthsolutions.com

PATIENT NOTICE PLEASE READ

WEB72 HOUR HOLTER MONITOR *PATIENT NOTICE – PLEASE READ* Dear Patient, In these unusual times we are doing our utmost to continue delivering excellent cardiac care.

Actived: 4 days ago

URL: https://referrals.m-healthsolutions.com/documents/72hours_instructions.pdf

Pocket Referrals

WEBPowered by m-Health Solutions Inc. ISO 13485 Certified 70 Frid Street, Suite 3 Hamilton, ON L8P 4M4 Phone: 1-888-636-0186

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Pocket Referrals

WEBPlease select the type of test: 72 Hour Holter Patch. 14 Day PocketECG Holter

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HOME SLEEP TEST FAX: 1-888-636-0181 [email protected]

WEBm-Health Soluons Phone: 1-844-636-0180 70 Frid Street, Unit 3 Hamilton, ON L8P 4M4 [email protected] www.m-healthsoluGons.com Please select:

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-636-01844 0 Phone: 1-8 www.m-healthsolutions.com -V1.

WEBName Gender ☐ M ☐ F Address Unit Physician Signature: Date: Clinic Copy KEEP IN PATIENT FILE City Postal Code Health Card Number Version Code DOB

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EMAIL REQUISITION TO: [email protected]

WEBName DOB Gender: M F Home: Hypertension Heart Failure Cardiovascular Disease Weight gain HOME SLEEP TEST EMAIL REQUISITION TO: [email protected] E-mail: …

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Signature: Date: atient P

WEBPhone: 1-844-636-0180. E-mail completed form to [email protected]. PATIENT INFORMATION PHYSICIAN'S INFORMATION. Note: The cost of this test is $249.00 …

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Referring Physician

WEBStatin. Oral Anticoagulant. Other: R/O A-Fib/Flutter Syncope. Known A-Fib/Flutter Palpitations. TIA/ Stroke. Chest Pain. Dizziness. Shortness of breath.

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