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Cardiology & Functional Medicine
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Tests
Conditions We Treat
Remote Holter Monitor
Cardiology & Functional Medicine
+44 7535 984 305
Referral Form
Please Enter Your Details and Your Patient’s Information in The Short Referral Form Below.
Name
The Name of your Practice
Email
Phone No
Your Patient's Information
Patient’s Name
*
Patient’s Date of Birth (dd/mm/yyyy)
*
Email
*
Patient’s Private Medical Insurance Company (if available)
Patient’s Private Medical Insurance Membership Number (if available)
What Is The Referral For?
Consultation (Remote/In-Person)
Test Interpretation
A Test
If a test, please indicate the type
Electrocardiogram (ECG)
Echocardiogram (Heart Echo Scan)
ECG Holter Monitor
Exercise Tolerance Test (ETT)
Exercise stress echocardiogram
24 h Blood Pressure Monitor
Cardiac CT
Cardiac MRI
Carotid Doppler
Arterial & Venous Doppler
Referral Notes
*
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