|
|
| |
Please send me more
information on your Holter/Cardiac Event Service
I would like to schedule a presentation with my local
representative |
| |
| Requested Tests For
The Facility |
|
|
|
 |
| |
|
| *
Name of Practice: |
|
| Physician Name (s) w/UPIN #s |
|
| *Contact Person: |
|
| Address1: |
|
| Address2: |
|
| *
City: |
|
| *
State/Zip: |
/ |
| *
Tel: |
|
| Fax: |
|
| Email: |
|
| |
|
| |
| Does your facility currently have Holters in
office?: |
Yes No
|
| How Many? (if Yes) : |
|
| How many Holter patients does facility either
hook- up or send-out per month? |
|
| Holter: Estimated Hook-ups Per Month?: |
|
| Suggested # of Recorders: |
|
| Send us Cardiac Events: |
Yes No |
| Suggested # of Cardiac Event Monitors: |
|
| *
How did you hear about us? |
|