KS Imaging Holter Diary (1)

Name

First NameLast Name

DOB

Hookup Date

Date

Patient ID- HEALTH CARD NUMBER

Monitor # - on back on monitor

Hookup tech / location

Reporting Physician: Dr Dokainish

72 Hours

Important Instructions to be followed while carrying the monitor: No shower for the number of hours stated above. Follow normal daily activities (food and medications Please write below in case you experience symptoms like dizziness, palpitations, shortness of breath or chest pain during the monitoring hours.

I agree to the above mentioned terms of carrying the monitor and will be liable for any damage caused to the equipment by paying an amount of $1915 either for repair/ new purchase of the equipment. I guarantee returning the monitor on the time specified by the clinic and for each 12h delay I will pay $120.

Please REMOVE monitor ( 72 hour from application date)

Please RETURN monitor on (72 hours from apt date in drop box)

Patient Signature