College of Veterinary Medicine

WSU Veterinary Holter Service

WSU Holter Service, Monitor Request Form


Please provide the following contact information: (*required)
THIS IS NOT AN ONLINE SUBMISSION FORM. This form must be completed, printed and submitted by mail or FAX.  Radio buttons may not print, please hand mark if needed.

Please submit a copy of pertinent medical records regarding the patient’s current history with this request form.

Use this form for requests to RENT equipment as well as to request Holter readings if you own equipment  
*Owners First Name
*Owners Last Name
Street Address
Address-Continued
City
State/Province
Zip/Postal Code
Country
Work Phone
*Home Phone
FAX
E-mail
Name of Veterinarian
Clinic/Hospital Name
Address of Veterinarian
Vet Address-Continued
Veterinarian's Phone Number
Veterinarian's FAX Number
Veterinarian's E-mail
   
Ship Holter Monitor to Owner Veterinarian
   

Animal Information
Animal's Name
Breed
Birth date Month Day Year
Gender female spayedfemale-not spayed male neuteredmale - not neutered
Weight specify pounds or kilograms

PLEASE PROVIDE THE FOLLOWING INFORMATION TO HELP US INTERPRET YOUR STUDY
Is this animal on any medications: Yes No
If medications are given, please list the name of the drug, amount given (milligrams) and frequency of dosing (once a day, twice a day, etc).
Has this animal ever had any episodes of collapse? Yes No
What other clinical signs (if any) has the animal exhibited?

Type of Service You are Requesting (please select one)
  Diagnostic Reading     $250
  Diagnostic Recheck    $150
If the owner or referring veterinarian owns a Forest Medical digital holter monitor and would prefer to record the reading and just send the data, please contact us for discount information.

Payment

CHECK (Checks for the complete amount should be made out to payable to WSU Veterinary Holter Service)
VISA MASTERCARD (Note: These are the only credit card types accepted)
Card Number
Expiration Date
VCODE**
Signature
**The last three digits of the number on the back of the credit card

Please complete the following if different than the name and address above

Name and Billing Address on Credit Card are the same as above
Name on Credit Card
Billing Address on Credit Card
Address-Continued
City
State/Province
Zip/Postal Code
 

EMAIL IS NOT SECURE. DO NOT EMAIL CREDIT CARD INFORMATION.

You may either print this form & hand-write the information OR complete this form on your computer & then PRINT the completed form. (This is NOT an online submittal form).

Please send the completed form & payment payable to:

US Mail Address

WSU Veterinary Holter Service
Department of Veterinary Clinical Sciences
PO Box 647060
Pullman, WA 99164-7060

FEDEx Shipping Address
WSU Veterinary Holter Service
100 Grimes Way
NVTH Room 3
Pullman, WA 99164

Phone: 509-335-0754
FAX: 509-335-7285
EMAIL: wsuholter@vetmed.wsu.edu
Last Edited: Oct 02, 2012 3:30 PM   

College of Veterinary Medicine, PO Box 647010 , Washington State University, Pullman WA 99164-7010, 509-335-9515, Contact Us  Safety Links