Clinic Appointments

Heart Rhythm Management is a comprehensive service that deals with electrical disorders of the heart. We aim to improve the quality of lives by correcting the electrical abnormality through ablation procedures and also provide an ambulatory cardiac device and monitoring service.

We work with your physician but patients can also contact us directly.

First name*

Last name*

Phone*

Email*

This is my:*

Cell phone

Work phone

Laptop

Other

I am: (Please choose 1)*

Patient

Referring Dr

Other health professional

Other

I was referred to this clinic by*

Upload File:

Drop a file here or click to upload

Maximum file size: 250MB

You can use this function to upload and attach files that will be needed in your appointment. This might include documents, x-rays, or scans.

Would you like to give us your medical aid information at this point?

Yes

It is optional to provide your medical aid information to us at this point. If you choose 'yes', additional fields will become available to you on this form. Please only fill in the information that you are comfortable providing at this time.

Please briefly describe your condition and symptoms *

Anything else you would like us to know?

Please use this space to give us any additional information that you think we should know before your appointment.