Physician & clinic resource
Cardiac diagnostic requisition.
A printable, one-page PDF for physician and clinic use.
Print at actual size on letter-size paper (8.5 × 11 inches). If the PDF opens in your browser, use its download or print button.
For your next clinic visit.
Testing is arranged through your doctor or clinic. Follow the appointment instructions provided by your healthcare team.
Returning a completed form
Contact your doctor or clinic for the appropriate way to return the requisition. Please do not upload completed forms or send patient information through the website inquiry form.
Need assistance? Call 416-660-7840.
Holter monitoring
Holter monitor patient form.
A two-sided form to give to patients when a Holter monitor is fitted. The front explains the test, how to care for the monitor, the late return policy and the patient agreement. The back is a Holter diary for recording symptoms.
Print double-sided on letter-size paper in landscape, flipped on the short edge, so the diary sits behind the patient panels.
