Online Holter Requisition Submit the the information below or click here to download the PDF. Patient Information First Name Last Name Phone Number Gender MaleFemale Date Of Birth Adult/Pediatric Adult (≥ 18)Peadiatric (≤ 17) Does patient have a pacemaker? NoYes Address Select ProvinceBritish ColumbiaOntario Health Card (With Version Code) Current Medications (Separate by comma) Clinic Information Referring Physician Physician Billing Number Fax Number Test Start Date Length Of Recording 3 Days14 Days Length Of Recording 1 Day Indications Abnormal ECGPalpitationsSyncope/Fainting SpellsPresyncope/Light-HeadednessChest Pain/Shortness Of BreathFatigue/WeaknessR/O Atrial Fibrillation/FlutterAtrial Fibrillation Rate ControlPost Stroke/TIAAtrial ArrhythmiaMedication EffectVentricular ArrhythmiaPacemaker VVIPacemaker DDD Other Indications (optional) Additional Comments Please add any additional comments below. Referring/Supervising Physician Signature Please use your mouse or touch to sign in the box below.