Ambulatory ECG Self referral form

ECG Testing from the comfort of your own home

Title Required

Patient First Name Required

Patient Surname Required

Gender Required

Date of birth (minimum age 18) Required

Phone number Required

Email Address Required

Patient Home Address

Address 1

Address 2

City

State/Province

Country

Postal Code

NHS number (if known)

Examination requested Required

7 Day ECG - Home Monitor Device

48hr ECG - Home Monitor Device

24hr ECG - Home Monitor Device

Why do you want this examination? Required

How long have you been symptomatic? Required

How long do your symptoms last for? Required

How frequent are your symptoms? Required

Do you have any underlying health conditions? Required

Are you allergic to any type of polyester or plaster? Required

Have you previously been fitted with a permanent pacemaker (PPM) or implantable cardioverter defibrillator (ICD)?: Required

GP practice name Required

NHS GP name

Address Required

Town / City Required

GP Postcode Required

It is a requirement that we communicate results to your NHS GP in order that they can make recommendations about your future care. By signing below, you acknowledge and accept that:

A copy of your report will be sent to your GP
Neither the physiologist who has analysed your recording or the Consultant verifying the report can discuss the findings of the investigation with you however, should we identify significant findings, you will be contacted with any recommendations.
You have read and understood the Patient information which you signed at the time of booking your investigation.

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I agree to the privacy policy.

Terms and Conditions

Ambulatory Electrocardiogram Self-Referral Form

Increasingly patients wish to take greater control of their own health and are becoming more aware of the opportunities to self-investigate their health issues, or simply reassure themselves that they are well.

To this end, Vista Health welcomes patients (“you”) who wish to refer themselves for an Ambulatory Electrocardiogram (ECG). You need to be aware of and agree to the following important information prior to proceeding with a self-referral booking:

You will need to complete a self-referral form, detailing the reasons why you wish to have the test. If it is for a medical complaint, this should be clearly stated. If it is for reassurance, that too should be stated.
Ambulatory ECG’s will only be offered to all those aged 18 and above.
We are unable to accept a self-referral from you if you are engaged in professional sports or for anything connected with a professional sports club of which you are a member.
The service is not suitable for patients who have previously been fitted with a permanent pacemaker (PPM) or implantable cardioverter defibrillator (ICD).
Following receipt of your referral, a member of our team will review the content and recommend a recording timeframe based on the information provided. For this reason, it is important you are honest with completing your self-referral form as this will ensure you are offered the most appropriate test. You will be informed if we are unable to proceed should our exclusion criteria be met.
You accept the recommendation made during triage is based on a clinical opinion following a review of your referral. You retain the right to request a shorter or longer recording duration however, you accept full responsibility should the test not be fully conclusive if you opt for a shorter recording then we have recommended.
Your use of the Equipment
You will be provided with an ambulatory ECG device by ECG On-Demand (“ECG On-Demand”)(“Equipment”). You will be provided with the required information and fitting instructions prior to the Equipment being provided.
If you are unable to fit the Equipment, you must contact ECG On-Demand in the first instance. If you feel the advice or guidance provided to you is unsatisfactory, please contact Vista Health.
You agree to engage with ECG On-Demand’s request to return the Equipment in good condition at the end of the recording. You agree that if you fail to return the Equipment following a written demand to do so, you will be liable to pay the full replacement cost of the Equipment.
You acknowledge that returning the Equipment late may adversely affect the monitoring and results available from the Equipment.
You acknowledge that returning the Equipment late means it will not be available in time to be cleaned and prepared for use by another patient, which could adversely affect that patient’s outcomes.
You agree to take good care of the Equipment and to use it only in accordance with any instructions provided.
You accept responsibility for any loss of or damage to the Equipment that occurs whilst in your possession.
ECG On-Demand accept responsibility for dispatch and collection of the Equipment using a reputable courier. Please ensure you retain your collection receipt as proof your Equipment was collected.
You consent for your personal data to be shared with ECG On-Demand and its associated partners as may be necessary in order for it to carry out its services. This might include without limitation communication to deliver/collect the Equipment and reporting on the Equipment’s recording.
You accept you are solely responsible for choosing the type of investigation and that you are not relying on any input in this regard, whether clinical or otherwise, from Vista Health.
You must be registered with an NHS GP, to whom a copy of the report will be sent and with whom all discussions about your future care must take place. We cannot enter into any such discussions with you.
We cannot perform investigations if you cannot, or do not wish to provide the name of your NHS GP.
You must understand that an ambulatory ECG may on occasion identify unexpected abnormalities which may or may not require further investigation. If so, these findings will be identified on the report and any recommendations arising will be followed up by your GP.
A physiologist will write the report which will be verified by a Consultant Cardiologist prior to being sent to your nominated GP within 3 working days of the investigation. This will include a clinical summary and any further recommendations.
The NHS and private medical insurance companies will not fund or cover self-referrals. All self-referrals are undertaken on a self-pay basis only.
Your full recording duration will be analysed. Please note that insufficient skin preparation, as outlined in the fitting instructions, can result in unclear ECG traces and reduce the amount of the recorded duration that can be analysed.
The provided report will include overview graphs and sample strips of any key times during the recording period e.g. maximum and minimum heart rates, patient events, rhythm disturbances. These strips will enhance the written report. Please note that it is not possible to provide a copy of every beat recorded due to the volume of data.

Ambulatory ECG Self referral form

Terms and Conditions

Ambulatory Electrocardiogram Self-Referral Form

Your use of the Equipment

By signing the referral form, you acknowledge that you have both read and agree to the above information.