Request a Monitor

TO BE COMPLETED BY THE VETERINARY SURGEON

The process of hiring a monitor is initiated by submitting an online request below. Until a completed form is received we cannot guarantee that a monitor will be available on a particular day.
Once a form is received, we will contact you by telephone or email to inform you which day the monitor will be sent to you.
In almost all circumstances a monitor will be available on at least one of the three dates you request.
The monitors are all supplied with full instructions for connection. If you have a technical query during connection then please email info@holtermonitoring.co.uk.
Please download and print an Owner Consent Form and ensure that it is completed by the owner prior to the monitor leaving your practice.

Vet's Details

Referring Vet Name*

Practice Name*

Practice Address*

Practice Postcode*

Telephone*

Email*

Recording Duration*
24h48h7 days

*Please give 3 dates in the format "dd/mm/yyyy" when the owner will be available to supervise the dog wearing the monitor for the entire duration of the recording:
1 2 3

Owner's Details

Owner's Surame*

Owner's Address

Owner's Postcode

Owner's Email

Pet's Details

Pet's Name*

Age*

Sex*

Breed*

Weight*

History and current clinical signs*

Current Treatment*

How did you hear about us?

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Please read the following points and then sign at the bottom of the page:

The monitor is an expensive (£1500) and sensitive piece of equipment and should be treated with care.

Most dogs and cats will tolerate the monitor well but they are unsettled then it may be necessary to remove the monitor.

The monitor is splash-proof but not waterproof, therefore please advise your client to use the waterproof coat provided if exercising the dog in the rain. If the dog swims whilst wearing the monitor your practice will be liable for the full cost of a replacement monitor.

The monitor should be returned to Holter Monitoring Service on completion of a recording. A surcharge of £20/day will be charged to the practice for monitors returned after the date stated on the invoice. This is because the monitor is needed for other dogs. The results of the recording will be sent to you within 7days.

The practice will be charged if the monitor is lost, damaged or if items such as the harness (£25 each) or the jacket (£20 each) are not returned.

By submitting this referral request I:

1. acknowledge that I have read the points listed above and accept liability for any damage to the monitor whilst it is in my care.
2. confirm that I have the consent of the above named client to pass the above information to you for the purposes of case referral; and
3. agree to be bound by the Holter Monitoring Service/Pets at Home Vet Group Privacy Policy (found at https://holtermonitoring.co.uk/privacy-policy/), which explains how the data I have submitted will be used.