PLACE LABEL HERE
HOLTER MONITOR
PATIENT AGREEMENT
I have received a Holter Monitor from Gwinnett Medical Center and agree to return this monitor to the issuing facility immediately upon completion of my test.
I hereby assume all risk of loss or damage to the monitor during its time in my care.
I understand that I must handle this unit with extreme care as it is a sensitive heart monitoring instrument and must perform properly to provide my physician with the results needed for an accurate assessment.
I understand that the monitor may not get wet as this may damage the monitor.
I understand that if I return the monitor in poor or unstable condition, I will be responsible for the repair cost.
I understand that if I do not return the monitor within three days from the completion of the monitoring period, there will be a charge of $2000.00 for which I, personally, will be responsible to pay directly to Gwinnett Medical Center to cover the replacement costs of the assigned Holter Monitor. Should Gwinnett Medical Center not be paid, Gwinnett Medical Center may take legal action.
By signing below, I have read, understand and agree with the above terms and conditions.
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PATIENT NAME (PRINTED) PHONE NUMER
____________________________________________________________________________
ADDRESS
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CITY, STATE, ZIP CODE
_____________________________ _________________________________________
DATE PATIENT or GUARANTOR SIGNATURE
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DATE TIME WITNESS
*1-33195* FORM 1-33195 INITIATED 03/2013 WHITE: Medical Record CANARY: Patient Page 1 of 1