I attest that the patient for whom I am submitting this requisition:

1. Is at least 18 years of age
2. Is not pregnant
3. Does not have an implantable device (Ex: Pacemaker, Defibrillator, Loop Recorder)
4. Gives consent to be contacted by Myant

Almost there! Please read and confirm:

By checking this box, I confirm that the patient has signed a consent form allowing me to share their private identifying information (including full name, date of birth, health card number, phone number, address, relevant medical history, and reason for study) with Myant Medical Corp. for Holter monitoring services.

I confirm this consent was knowledgeable, voluntary, and not obtained through deception or coercion as required by the Personal Health Information Protection Act (PHIPA) of Ontario.

I understand that the patient has been informed about the purpose of sharing this information, their right to withhold or withdraw consent at any time, and that I remain responsible for maintaining appropriate documentation of this express consent in the patient's medical record.