VEST FOR CARDIAC MONITORING
1155 Elm Street, York PA 17403
800-313-1218 • 703-715-0300 • fax: 703-391-9333
CLINIC INFORMATION (print clearly)
Email: [email protected]
Name of Clinic:
Veterinarian:
Clinic address:
City:
Phone: _______________________________
Email:
State: __________ Zip: _________________ Country: ____________________
BILLING INFORMATION (print clearly)
(Required) 3 or 4 digit security code
Credit Card #: ________________________________________ Expr: _________ Security Code: __________________
Signature:
Phone:
Who’s card is this (Please circle one)
Clinic card
or
Client card
Billing address:
City:
State: _________ Zip: _________________ Country:
SHIPPING INFORMATION (print clearly)
Ship to: CLINIC ____
OWNER ____
Ship by: FedEx Ground ____
3-Day ____
2-Day ____
Overnight ____
International ____
Ship to address (if different than card):
City:
State: __________ Zip: _________________ Country: _____________________
PET & OWNER INFORMATION (print clearly) Please complete if for a specific pet, otherwise indicate “Clinic Use”
Owner’s Name:
Phone:
Email address:
How do you hear about us:
Pet’s Name: ____________________________ Pet’s Breed: ____________________________ Age:
Diagnosis:
Weight:
Does pet have: Cushing’s disease _______
Addison’s disease ______
Severe skin allergies ________
MEASUREMENTS:
(CIRCLE ONE)
Compromised immune system _____
Long-term steroid therapy ______
Inches
Centimeters
Diabetes ______
(print clearly)
Measure the circumference of the chest immediately behind the front legs (at its deepest point).
Chest
Length
Size
Chest
Length
Size
10" - 13"
5.75"
XXXS
Quantity
25" - 27"
12"
M
14" - 16"
6.5"
XXS
28" - 34"
12"
M/L
17" - 19"
7"
XS
35" - 39"
13"
L
20" - 22"
8.5"
S
40" - 43"
14.5"
XL
23" - 25"
9"
S/M
44" - 58"
16"
XXL
MONITOR DEVICE
Monitor manufacturer/Model#:
Lead Orientation:
Effective 2/16
RemotePortableVESTMonitor_order.doc
Dimensions (L x W x D):
Quantity:
Quantity