First-Call Medical - Equipment Request Form

E-Mail Request Form

To enroll in the First-Call Medical service and request your overnight delivery of equipment, supplies, and instruction manuals fill out the form below.

There is no capital investment necessary and you will not be asked for any credit card information.

Indicate the Recording / Monitoring Equipment and the Quantities you Require
Qty	Equipment
	King of Hearts Express (pre- and post-symptom cardiac event recorder)
	CardioMemo (post-symptom cardiac event recorder)
	HeartCard (post-symptom cardiac event recorder)
	2-Channel Holter Recorder

Check the box next to the Items you require below:
Cardiac Event Monitoring Supplies
Cardiac Event Monitoring Instruction Manuals
Cardiac Event Monitoring Case Studies, Diagnosis Codes, Billing Codes
Holter Monitoring Supplies
Holter Monitoring Instruction Manuals
Holter Monitoring Case Studies, Diagnosis Codes, Billing Codes

Fill out the following contact information:

Account Name:
Contact Person:
E-Mail Address:
Phone Number:
Fax Number:
Mailing Address:
City, State & ZIP:
Start date:
Specialty:
Unique Physician Identification Number: Do you require any additional information?:

Thank you

First-Call Medical, Inc., \| Nationwide 24-Hour Holter, Event, Pacemaker & Blood Pressure Monitoring \| 574 Boston Road Billerica, MA 01821 \| 800 274 5399 \| info@fcminc.com
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