Satellite Monitoring Request Form

Fertility Satellite Monitoring

This form must be completed by the ordering provider/clinic
Terms & Conditions

For use of Satellite Monitoring services
We are happy to be able to work with you and your clinic to provide colaborative health care services for your patient. Before we move forward the following terms and conditions must be reviewed.

Vena Women's Health & Wellness (a divisions of Vena Mobile Health Inc.) is soley acting as an order transcribing clinic. Any and all of our associated medical professionals will not be deemed responsibile for the oversight of care and well-being of your patient while they are undergoing treatments with you at your Naturopathic Doctor's clinic.

Vena Women's Health & Wellness and our medical professionals will not be held responsible for any adverse reactions associated with the medications you have been prescribed by your original and responsible ordering provider of the test results and medications that have been prescribed. We will not be responsible for any pre and/or post cycle follow ups, emergency care, or patient questions relating to the testing and prescriptions.

Please ensure the patient has been seen and has spoken with you, the primary care provider, and all orders and medication instructions have been reviewed and understood. Vena Women's Health & Wellness will not review the orders or medications with the patient.

It is imperative that you will be available to contact to answer any questions that may arise during the transciption process.

Vena Women's Health & Wellness maintains the right to refuse any transcribing services if the request/orders are unclear and missing vital information such as dosing, quantity, and administration instructions.

By checking the box below, you and the patient are agreeing to these terms and conditions and will ensure you refer to your clinic for continued care during the treatment with your clinic.
*We do require a credit card be added to your online profile BEFORE we can provide any satellite Monitoring services. To avoid any delays, please ensure your online profile is completed and all of the required documentation has been submitted with this form.

There is a one time $40.00 set-up fee for our Satellite monitoring patients. The fee will be charged once we have recieved all of the required documentation and your profile has been completed.
Patients Name

First NameLast Name
Date of Birth

DayMonthYear
Provincial Health Care Number
Gender
Phone Number
Address

Street Address

Street Address Line 2

City Province

Postal Code
Email
example@example.com
Pharmacy Fax number *
Please enter a valid fax number.
Referring Provider Information
Provider Name

First NameLast Name
Prac ID (if applicable)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
What treatment is the patient undergoing?
What services are being requested by Vena Women's Health & Wellness? Select all that apply.

Prescription TranscribingUltrasound - baselineUltrasound- Follicle MonitoringBlood work
Anticipated Start Date of services

MonthDayYear
Date
Satellite Patient Co-Ordinator

Who is the Satellite Patient coordinator at your clinic
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Please attach patient orders here. (medications, blood work, ultrasounds)

Cancelof
Patient Signature

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Fertility Satellite Monitoring

Terms & Conditions

Referring Provider Information

Satellite Patient Co-Ordinator