Echocardiography & Holter REFERRAL.

Adult BSE-accredited echocardiography is offered at the clinic. Only GP or Specialist referrals will be accepted using this form. Please complete all fields or requests may be rejected. It is advisable that your patient attends with formal reports of most recent cardiac imaging and/or clinical correspondence.

1- and 7-day Holter monitoring services are available. These monitors are activated and assigned to the patient at our clinic, then either fitted on attendance, or can be collected and self-fitted at home by the patient. They are returned either in person or by post. Loss or damage to these units will incur a fine. Terms and Conditions are detailed in the link below.

At present our clinical facilities are on the first floor, with only stair access. We apologise if we are therefore unable to accommodate your patient.

Terms and Conditions
Clinic Fees

Patient Name

First Name

Last Name

10-Digit CHI Number

Patient Address

Holter units, if relevant, are posted to this address. Please ensure accuracy.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient Email

Patients will receive appointment details/reminders and a copy of their report to this address.

Patient Mobile Number

Appointment details/reminders will be sent to this number.

(###)

###

####

Clinical Details of Request

Referring Clinician's Name

First Name

Last Name

GMC Registration No.

Registered Clinic Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Clinician/Clinic Email

Personal emails will not be accepted. Please provide your NHS or official Private Practice email address. Reports will be sent to this address.

Consent, Chaperone & Accessibility

Please tick where the answer is 'yes'.

Does the Patient provide consent for their results to be emailed to them and their requesting Practitioner?

Is the Patient aware of the cost of the service and any additional consultation or test that may be advised?

The Patient has requested a chaperone.

The Patient is able to manage one flight of stairs to the clinical floor.

Payment Method

Self-paying

Private Insurance (BUPA, AXA, Vitality, Aviva, Cigna)

Please email any existing echo/holter reports along with your referral, if felt relevant, to admin@hourglasswellbeing.com.

Echocardiography & Holter REFERRAL.

HoURGLASS WELLBEING CLINICS & TRAINING ACADEMY

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