Request a new Patient
I hereby state that I have examined the patient and have determined that the test ordered is medically necessary due to the patient's symptoms and/or medical condition. The results of this test will be used to aid in the diagnosis and treatment of this patient. This patient is at low risk of developing ventricular tachycardia/fibrillation and would not be more appropriately cared for in a hospital setting. This is not a screening procedure. Physician agrees that Nuubo LLC is providing only the technical component of the test. Physician is responsible for ensuring that correct indications are documented, including providing and documenting any physician review required by Medicare or other applicable third party insurance payers.
Patient ID *
Healthcare Center's Name (Do not change it) *
Prescribing Physician *
Patient's first name
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Patient's last name
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Patient's Address *
Clinical Indication *
Monitoring Days  *
Request Status *
Patient's Phone Number (only numbers, ex. 7652341665) *
Emergency Contact *
Emergency Contact Phone number *
Patient's Insurance Company *
Patient's sex *
Patient's date of birth  *
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Physician Consent for Study? *
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