PRIMA HOLTER 3 DAY RENTAL SIGN UP

Fill out and submit the form below.
At the bottom of this page, after the form - download, sign/date, and email the signed contract to shayna@primadobermans.com

Name

First Name

Last Name

Email

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please list the dog(s) name, breed, age, and gender that will be tested:

Why are you interested in renting a holter monitor?

Have you ever hooked up a holter?

Has your dog(s) ever had a holter hooked up? How did they do?

Has your dog(s) had an echocardiogram by a licensed cardiologist within the last year?

Do you have a deadline for your holter report such as the 90 days from Echo or for a breeding coming up? If yes what timeframe?

Do you have access to a computer with USB and internet for your report?