Online Monitor Request Form Online Monitor Form for Veterinarians Please enable JavaScript in your browser to complete this form.Clinic:Date:Client Name:Patient Name:Breed:Age:Sex:Male, IntactMale, NeuteredFemale, IntactFemale, Spayed Weight:Veterinarian:Phone:Fax:Reason for Monitoring:Current Medications (include dosage and frequency given)Radiographic Findings (if none have been taken enter N/A)Lab Abnormalitities (if none have been done enter N/A)Application Date Requested:We will attempt to accommodate your scheduling needs to the best of our ability, based on current availability. Requests should be received before 3PM EST, for same day shipment, if Holters/CERs are available.Please Select One: *Holter Monitor (24 Hour)CER Monitor (7 days)Monitor Vest Size Options (Choose One): *XS (14.5"-20.5")S (19"-26.5")M (23.5"-31.5")L (28.5"-36")XL (30.5"-40")• Please schedule patient appointments carefully. Holter monitors are worn for 24 hours and CERs are event monitors worn for 7 days; you will receive a return date when the monitor arrives. Please note, that when the monitor is shipped it will arrive at your clinic between 3PM and 5PM the next day. An additional fee will apply for a morning delivery if desired. A $10 late charge per day for monitors returned beyond the scheduled due date will be applied. All late fees accrued will be charged to the credit card provided.• Instructions for placement of the monitor must be followed exactly as provided, or the study may be non-interpretable. Refunds will not be issued if the study is non-interpretable. All monitors have passed quality inspections prior to shipment.• You will receive a preliminary report within 24 hours of the return of the monitor to verify the receipt and that the data is readable. At this time you will be given an approximate processing time for final results to be available.• Total fee includes equipment, supplies, next afternoon shipping to and from your clinic (morning shipment is available for an additional charge), and interpretation with a written report. Please call for pricing.• If, for any reason, the monitor is not used, your account will be credited 50% of the total fee following its return, inspection, and payment of any late fees.• All monitors are paid for by your clinic's credit card.• By signing this agreement, you agree to be held responsible for the cost of replacing or repairing the monitor or its accessories if lost or damaged. Please note replacement cost for the unit is approximately $2500.00.WebsiteSubmit