College of Veterinary Medicine

Veterinary Cardiac Genetics Lab

Canine Holter Monitor Service 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
Use this form for requests to RENT equipment (service plans B & C) as well as to request Holter readings if you own equipment (service plan A)

*First Name
*Last Name
Street Address
Address-Continued
City
State/Province
Zip/Postal Code
Country
Work Phone
*Home Phone
FAX
E-mail
Alternative E-mail

Animal Information

Animal’s Name:
Breed
Birthdate: Month  Day   Year
Gender  female spayedfemale-not spayed  male neuteredmale - not neutered 
Weight: specify pounds or kilograms
Date of Exam Month  Day   Year

PLEASE ANSWER THE FOLLOWING QUESTIONS 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
Please Select a Service Plan
Service Plan A:  Pre-Breeding Screen ($65/tape; Cardiologist interpreted; Owner supplies equipment)

Service Plan B: Pre-Breeding Screen ($100 Deposit required at time of order to be deducted from balance due; $135 for 1st dog and $95 for each additional dog; WSU supplies equipment).

Service Plan C: Diagnostic Screen ($100 Deposit required at time of order to be deducted from balance due; $250 for each dog; WSU supplies equipment).

Payment

CHECK (Checks should be made out to payable to VCGL-WSU)

VISA  MASTERCARD  (Note: These are the only credit card types accepted)


Card Number  Expiration Date    VCODE**
Signature       

**The last three digits of the long number on the back of the credit card generally located close to the signature line.

NOTE: In order to process a credit card, the following information is required: Name of card owner (as it appears on the credit card), mailing address of card owner, card number, card expiration date and card’s VCode (3 digits on back of card).

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, completed tapes & check payment payable to VCGL-WSU to:

Dr. KM Meurs
Veterinary Cardiac Genetics Laboratory
Washington State University
Post Office Box 605
Pullman, WA 99163

If you have questions or to request equipment, please call Dr Meurs or Esther Wilson at 509-335-6038 during regular office hours or EMAIL  holters@vetmed.wsu.edu

Contact VCGL Canine Holter Monitor Service

Veterinary Cardiac Genetics Laboratory
Washington State University
Post Office Box 605
Pullman, WA 99163
Phone: 509.335.6038
FAX: 509.335.6038
EMAIL: holters@vetmed.wsu.edu


Last Edited: Feb 13, 2009 5:55 PM
Veterinary Cardiac Genetics Lab, PO Box 605 , Washington State University, Pullman WA 99163-0605, 509.335.6038, Contact Us   Safety Links