Patient Details Form

Specialists in Cardiology

Please Fill In Your Personal Details

So our staff can better assist you, please fill in and submit your personal details

Note: Please make sure to carefully read the terms and conditions before submitting

Terms & Conditions

1 – The equipment is supplied for the maximum period detailed above and is due to be returned on or before the date and time specified. The equipment is to be used only for the specific use of the patient named above.

2 – Heartscope will keep the equipment in good condition and will test that it is fully working and in good order prior to issue. The patient, in accepting the equipment, warrants that they will cover loss or damage (including accidental damage) to the equipment both in the home and elsewhere whilst under their control. The patient agrees that in the event of such loss or damage arising they will immediately inform Heartscope. The current replacement cost of the ECG Holter and BP Monitor is $2,000/‐ whilst the Embletta/Nox sleep study unit is $ 7,500/‐

3 – The patient will not modify the equipment or attempt to open the equipment or use it in any way inconsistent with its purpose.

4 – The patient is responsible for the return of the equipment by the due date without reminder and must sign the “Acknowledgement of return form” after the return equipment has been verified by a staff member. If the device is not returned on the due date and time, a late fee of $ 50 per day will be charged.

5 – The term may be extended only by the written agreement of the Practice in the form of a new agreement form covering the extended period. Heartscope will instruct the patient on the correct use of the equipment, however is not responsible for failure to use the equipment correctly once it has left the premises.