Referring Physician: OFFICE STAMP

Name

DOB Health Card Number Version Code

CC:

Pacemaker

Implanted Cardiac

Defibrillator

ASA

ACE Inhibitor

ARB

Beta Blocker

Statin

Other:

Other:

Phone

Cardiac Diagnostic Service

REASON FOR REFERRAL

PATIENT INFORMATION

CURRENT MEDICATION(S)

City Postal Code

Gender: M F

Address Unit

Name Fax number

A-Fib/Flutter R/O

Chest Pain

Dizziness

Palpitations

Shortness of breath

Syncope

Our Cardiac Center will contact you within 1 business day to explain the test procedure. If you have any questions in the meantime, please call us at:

1-888-636-0186Mon.-Thurs.: 9am - 7pm, Fri.: 9am - 5pm, Sat.: 11am - 4pmPlease visit our website to watch the instructional video or read the frequently asked questions : www.heart-health.ca

m-CARDS TM

mobile-Cardiac Arrhythmia Diagnostic Service

v 2.0

Physician Signature: ________________________ Date: _______________Please tear bottom and give to patient

PHYSICIAN ACKNOWLEDGEMENT: By referring the above patient for the m-CARDS TM service, I acknowledge I have completed the patient education and technical set-up as outlined on the reverse side of this form.

FAX REQUISITION TO: 1-888-636-0181

q 2 Weeksq 4 Weeks

Test Requested:

IMPORTANT:

This test is for diagnostic purposes only, in case of emergency contact 911 or go to nearest hospital.

1. Kit Delivery

• Your cardiac monitor will be delivered by Canada Post. We will call you before shipping to confirm your address. Once your address is confirmed, you can expect the monitor to be delivered within 2-3 business

days.

4. Returning the equipment

• We will call you the day before your test is over to let you know. A pre-paid/pre-addressed return envelop will be included in your kit for you to return the equipment to us once your test is over. You can drop it off in any Canada Post mailbox.

3. Starting the test

• Once connected you can start the test by inserting the battery provided in

the monitor.

• Within 30 seconds of inserting the battery you should see the screen on the right. Press ‘Start Session’ to begin your test.

2. Electrode placement

• You will need to prepare the area on your skin for 3 electrode patches as shown on the right. For each area wash your skin with soap and water and shave area if necessary (do not use any oil or lotion).

• Apply the electrode patches to the prepared area. Each electrode patch can stay on for up to a week. Replace earlier if they are peeling off, or if the monitor indicates you should replace them.

• Connect each lead wire of the heart monitor to the corresponding electrode patches.

At the end of the test m-Health Solutions will contact you to let you know that the test is over.

Questions? Please call us at 1-888-636-0186

0

INFORMATION ABOUT THIS TEST