PATIENT  ENROLLMENT  FORM

Please scroll down to complete the form below, which includes the following sections:

  • Study Details
  • Requesting Physician Information
  • Patient Information
  • Next of Kin or Alternate Contact Details
  • Patient Insurance Details
  • Authorization and Form Submission
Please note, the initials at the bottom signifies the patient’s acknowledgement of the return of the monitoring equipment within 48 hours of the end of the study.
  • For any questions regarding the MCT implementation process or form completion, please contact ARTELLA by email (info@artellainc.com) or phone (713) 821-3200.
Thank you!

Study Details





Duration of Monitoring

Here are some common diagnosis codes for cardiac monitoring: R00.2 (Palpitations), R55 (Syncope and collapse), I48.0 (Paroxysmal atrial fibrillation), R00.1 (Bradycardia), R42 (Dizziness and giddiness), R00.0 (Tachycardia), I47.1 (Supraventricular tachycardia), I49.9 (Cardiac arrhythmia).

Requesting Physician

Patient Information

Next of Kin or Alternate Contact Details

Patient Insurance Details

Authorization and Submission

I authorize the above ordering physician to release any necessary medical or demographic information concerning above named patient to Artella Solutions Inc. I acknowledge responsibility for the assigned Artella Solutions monitor. Upon completion of service, I will return the monitor in good working order to Artella Solutions Inc. Failure to do so will result in my being charged $1850.00 for replacement of the monitor. If not returned within 36 hours I will be charged $150.00 per day until returned.