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Simple ECG Web Prescribing Questions:

Billing Information for SimpleECG. - Medicare Code 99444 - CPT Code for Arrhythmia 427.89
*Required Fields
PATIENT INFORMATION
*First Name
*Last Name
*Address
*City
*State
*Zip
NOTE: For residents living outside of UT, WY & NV, please click here for ordering information.
*Age
NOTE: You must be 18 years of age or older to purchase the SimpleECG.

Yes   No
*I consent to having an online evaluation by the Simple ECG Physician and consent to receive a prescription from him. I agree to an arbitration agreement for any legal claims against the Simple ECG prescribing physician. I have read and agree with the Privacy Policy and Terms & Conditions of this web site.

CONSULTATION - PHYSICIAN INFORMATION
Yes   No
*Do you have a pacemaker?
Yes   No
*Do you have an implanted defibrillator?
Yes   No
*Have you had a prior cardiac arrest?
Yes   No
*Do you have Parkinsonism or a tremor that would make recording difficult?
Yes   No
*Do you have use of both hands?
(A prior Stroke would make holding the device difficult)
Yes   No
*Are you able to read newsprint with or without corrective lenses? (The device requires ability to read a small screen).
Do you have any specific questions you would like to ask the Doctor?
DISCLAIMER: Chest pain, shortness of breath with sweating are all serious symptoms which require immediate attention by a physician. If you are experiencing any of these signs, please contact a physician immediately.
Yes   No *Would you like H&H Medical to contact your personal physican about the Simple ECG and forward him/her product information? If yes, please complete "Physician Informaiton".
Physician Information:
Name Address
City State
Zip Phone
E-mail Fax

H&H Medical Corporation
info@hhmedicalcorp.com • 801-349-2708 • Toll Free: 866-370-2434
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