VVS Holter Request Form
Referring Vet Details:
FIRST NAME
SURNAME
Referring Practice Details:
PRACTICE NAME
POSTCODE
Email Address for Holter Report:
*
Invoice Email Address (if different from above):
Patient Information
Patient details:
*
Please upload a copy of the patient records. Maximum file size is 300MB. Larger files please email to info@vvs.vet
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Which Holter length do you require?
*
Please Select
Please advise most appropriate length for my patient
24 hours
48 hours
7 days
Please select your preferred date for the Holter to arrive.
Please note this subject to availability
We recommend booking the fitting appointment with your client once you have received confirmation that the Holter has been dispatched. Please arrange a fitting appointment within 1 week of receiving the Holter.
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Day
-
Month
Year
Date
Please provide a brief clinical history (including medications and doses):
*
TERMS AND CONDITIONS:
The Holter monitor is a valuable specialised digital recording device. It is NOT waterproof. Patients should be carefully observed whilst wearing it and appropriate precautions taken to prevent damage of any kind. Non-returned or damaged monitors will be charged in full (£2000+ VAT). Non-returned or damaged Holter vests will be charged in full (£100+ VAT). Non-returned or damaged Holter lead set will be charged in full (£200+ VAT). Please note that where a VVS Holter is delivered but not subsequently fitted, we reserve the right to invoice for the associated courier and handling fees (£60+VAT). We request that you communicate these fees to your client prior to the fitting of the Holter monitor.
DISCLAIMER:
*
I agree that the patient information provided is complete to the best of my knowledge. I accept that VVS are only able to provide this service based on the information provided. I accept that the primary responsibility for this case remains with the referring clinician. I acknowledge that VVS may need to contact me for further information ahead of confirming my report.
I agree to the Terms and Conditions outlined above and have communicated these charges with my client. I acknowledge that any charges incurred will be invoiced to the practice.
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