Holter Monitor Patient Agreement

Please complete the form below.

Dear Boerne Veterinary Client:

Please read and sign the below requirements for use of the Holter Monitor. Please keep an activity diary for the next 24 hours while your pet is wearing the Holter.

Monitor must be removed and returned to the Boerne Veterinary Clinic reception desk within 24 to 48 hours from the date and time that you receive it. Unless previous arrangements have been made all guidelines and directions given to you on the care of the monitor must be followed as you were instructed. The monitor with lead wires and vest must be returned in the same condition as it was when you received the equipment.

IF THE MONITOR IS RETURNED IN POOR OR UNSTABLE CONDITION, YOU WILL BE RESPONSIBLE FOR THE REPAIR COST. IN THE EVENT THAT THE MONITOR IS NOT RETURNED YOU ARE RESPONSIBLE FOR THE ENTIRE COST IN THE AMOUNT OF $1700.

IN CONSIDERATION FOR USE OF THE HOLTER MONITOR, I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE REQUIREMENTS. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO RETURN THE PROPERTY.

Owner Name *

First

Last

Email *

Patient Name *

Age/Date of Birth *

Date / Time *

Date

Time

Signature

Please read and sign the below requirements for use of the Holter Monitor. Please keep an activity diary for the next 24 hours while your pet is wearing the Holter. Monitor must be removed and returned to the Boerne Veterinary Clinic reception desk within 24 to 48 hours from the date and time that you receive it. Unless previous arrangements have been made all guidelines and directions given to you on the care of the monitor must be followed as you were instructed. The monitor with lead wires and vest must be returned in the same condition as it was when you received the equipment. IF THE MONITOR IS RETURNED IN POOR OR UNSTABLE CONDITION, YOU WILL BE RESPONSIBLE FOR THE REPAIR COST. IN THE EVENT THAT THE MONITOR IS NOT RETURNED YOU ARE RESPONSIBLE FOR THE ENTIRE COST IN THE AMOUNT OF $1700. IN CONSIDERATION FOR USE OF THE HOLTER MONITOR, I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE REQUIREMENTS. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO RETURN THE PROPERTY. *

Clear Signature