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Welcome to Sana Alliance
Referral
Welcome to Sana Alliance
Referral
Referring your patients
Download our PDF referral document by clicking the button below
Download referral form
Referral form
If you prefer to use the offline referral form, please use the button above to download it.
First name
Last name
Address
Phone number
Email
Birth date
Insurance
Reason for recording
Not selected
Palpitations
Afib screening
Dizziness
Syncope
Optimising treatment
Other
Period of recording
Long-term ECG 1 day
Long-term ECG 2 days
Long-term ECG 3 days
Long-term ECG 4 days
Long-term ECG 5 days
Long-term ECG 6 days
Long-term ECG 7 days
Submit
