OFFICE STAMP - m-Health Solutions

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OFFICE STAMP - m-Health Solutions
Referring Physician: ____________________________
OFFICE STAMP
3190 Harvester Rd. Suite 203
Burlington, ON L7N 3T1
Phone: 1-888-636-0186
FAX REQUISITION TO 1-888-636-0181
PATIENT INFORMATION
Name:
Gender:
Address:
Height:
Health Card Number
Name: Weight:
Home:
Work:
Cell:
Postal Code:
D.O.B.: (dd/mm/yyyy)
CC:
F
Telephone:
Unit:
City:
M
Version Code:
Fax number:
PRE-EXISTING CONDITION
q
Atrial Fibrillation/Flutter
q
History of CVD
q
Bradycardia (<
q
Hypertension
q
Conductive disturbances
q
Tachycardia (>
)
)
q
TIA Stroke
q
Ventricular arrhythmias
q
Other:
REASON FOR REFERRAL
q
q
q
q
q
q
q Post Stroke/TIA
q Drug therapy evaluation: _____________
Abnormal ECG
q Pre Op/ Post Op/ Post ablation
q
Dizziness/
loss
of
balance/
coordination
Atrial Fibrillation/Flutter R/O
q Shortness of breath
q
Light-headedness
Bradycardia (<
)
q Syncope/fainting spells
q
Palpitations
Chest pain
q Tachycardia (>
)
q Post MI follow up
Conductive disturbances
Other: _________________________________________________________________________________________________________
CURRENT MEDICATION(S)
q
q
q
q
q
q
q
q Beta Blocker
ACE Inhibitor
q Coumadin (Warfarin)
Amiodarone
q Dabigatran (Pradax)
Amlodipine (Norvasc)
q Digoxin
Apixaban (Eliquis)
q Diltiazem
ARB
q Diuretic
ASA
Other: ____________________________________________
q
q
q
q
q
q
Heparin
Nitroglycerin
Rivaroxaban (Xarelto)
Sotalol
Statin
Verapamil
q Pacemaker
q Implanted Cardiac
Defibrillator
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.
Test Requested:
q 2 Weeks
q 4 Weeks
Physician Signature: ________________________ Date: _______________
Please tear bottom and give to patient
m-CARDS TM
mobile-Cardiac Arrhythmia Diagnostic Service
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:
1-888-636-0186
Mon.-Thurs.: 9am - 7pm, Fri.: 9am - 5pm, Sat.: 11am - 4pm
Please visit our website to watch the instructional video or
read the frequently asked questions : www.heart-health.ca
Cardiac Diagnostic Service
v 1.3
PHYSICIAN CHECKLIST
PATIENT TECHNICAL SET-UP
ELECTRODE
PLACEMENT
Patient
Education

Prepare the following 2 areas for electrode placement by washing with soap and water (and shaving if
(for referring
necessary):physician to review with patient):
1. Upper right, midway on the clavicle.
diagnostic
purposes only,
case
medical
 This
test is
2.for
Lower
left, mid-clavicular
line oninthe
5thof
ora6th
rib. emergency the patient should
contact 911 or go to the nearest hospital.

Place an electrode patch on each of the 2 prepared sites.
 This
is a 2 week (14 days) or 4 week (28 days) test.
NOTE:

Electrode patches can stay on for 3-4 days before they need to be replaced (or until the heart device
will‘ELECTRODES’).
be shipped to the patient’s designated address for self hook-up. Please verify
 The
monitor
says
that the address on the enrollment form is the patient’s current mailing address.

If skin becomes irritated, try changing the position of the patch slightly.
diagnostic
kit with
is thea lead
property
of m-Health
Solutions
Inc. The
patient
is responsible
for the
  The
The
kit will come
wire. Connect
the white
snap button
of the
lead wire
to the
diagnostic
equipment
(external
diagnostic
and the
for the duration
electrode on
the right clavicle
and cardiac
the red snap
button todevice
the electrode
onBlackBerry)
the left.
of
the
testing
period.
Quick tip to remember: white on the right, red close to your heart.
PATIENT EDUCATION

 The patient will return the testing equipment promptly at the end of the testing period in
Thisworking
test is fororder.
diagnostic purposes only; in case of a medical emergency contact 911 or go to the nearest good
hospital.
Cardiac
Testing
Centeralways
will contact
thetopatient
periodically
at
  The
When
you feel
a symptom
remember
press the
green buttonduring
on the the
hearttesting
monitor.period
It is also
the
designatedthat
phone
number. aPlease
verify
that
the
phone
numberononthethe
enrollment
form is
recommended
you complete
symptom
diary.
You
can
do so directly
BlackBerry
(instructions
on
how
to
do
so
are
included
in
the
kit)
or
you
can
phone
our
cardiac
center
to
report
it.
the patient’s current phone number. Agents are available to the patient throughout the

course
of the test should they have any questions.
The heart monitor will turn off after 2 minutes of being disconnected. To turn it back on simply press and hold the center green button until the display comes up (remember to turn it back on after taking a shower).
Set-up
 Technical
Always keep
the BlackBerry within 30 feet (10m) of you and remember to charge it nightly.
placement
 Guidelines
If you dofor
notelectrode
have cell reception
where you are, do not worry, all the information will be stored on the
 Wipe
BlackBerry
and
we willswab
receive
when you come
back into cellular coverage or the kit is returned.
with the
alcohol
theit following
2 areas:

The diagnostic kit is the property of m-Health Solutions Inc. You are responsible for the diagnostic
1) Upper
right,
midway
clavicle for the duration of the testing period.
equipment
(heart
monitor
andon
thethe
BlackBerry)
2) Lower left, mid-clavicular line on the 5th or 6th rib

You must connect immediately upon receiving the kit and return the equipment promptly at the end of the  When
testing
period
in good
working
the
alcohol
on the
skin order.
is dry, place the two electrode patches as is shown in the picture

below.
This is a 2 or 4 week test.
  Do
We
will
call you at the
of your
test and
you on how
to return
the kit
pre-paid
envelop is
not
press/touch
theend
centre
portion
ofinstruct
the electrode
patches
where
the(agel
is located.
included in kit).
Ensure adhesion of the electrode patches by pressing the edges firmly.
ImportantInforma�
Information
aboutthe
theTest
Test
Important
on about
1) Upper right
q Thistest
testisisfor
fordiagnos�
diagnostic
purposesonly,
only,inincase
caseofofemergency
emergency This
c purposes
contact
contact911
911or
orgo
goto
tonearest
nearesthospital.
hospital.
q Atthe
theend
endofofthe
thetest
testm-Health
m-HealthSolu�
Solutions
willcontact
contact you
At
ons will
you
to let
know
the
test
over.
to let
youyou
know
thatthat
your
test
is is
over.
If
cul�esduring
duringthe
theTest,
test,
q Ifyou
youexperience
experiencetechnical
technicaldiffi
difficulty
disconnect
the
electrodes
and
call
us
at
1-888-636-0186
disconnect the electrode and call us at 1-888-636-0186.
2) Lower leŌ

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