Online Patient Referral Submit the online requisition below or click the referral button to download the PDF. Click to Download Patient Referral PDF . Patient Information First Name Last Name Phone Number Gender MaleFemale Date Of Birth Address Select ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Health Card Current Medications (Separate by comma) Physician Information Referring Physician Physician Billing Number Phone Number Fax Number Diagnostic Testing 2D ECHO AND COLOUR DOPPLERTREADMILL STRESS ECHO12 LEAD ECG24 HOUR AMBULATORY BLOOD PRESSURE MONITOR (Not covered by OHIP)HOLTER MONITORING [group Decho] 2D Echo and Colour Doppler Indications Heart MurmurNative Valvular StenosisNative Valvular RegurgitationKnown or Suspected MVP with MRProsthetic Heart Valve(s)[/group] [group treadmillstressecho] Treadmill Stress Echo Indications Screening for CAD - Moderate-High risk for CADScreening for CAD - Chest Pain on the Background of Multiple Coronary risksCAD - Follow-up Post InterventionCAD - Follow-up on Medical TherapyExertional DyspneaValvular Stenosis - Exercise Capacity and LV Contractile ReserveValvular Regurgitation - Exercise Capacity and LV Contractile ReserveProvocable LVOT Obstruction[/group] [group holter-monitoring] Holter Monitor Length of Recording 3 Days14 Days Holter Monitor Indications Abnormal ECG (AV Block, Bundle Brunch Block)PalpitationsSyncope/PresyncopePost CVA/TIADyspnea/Chest PainWeakness/FatigueRule Out A-fib/FlutterA-fib Rate controlAtrial ArrhythmiaVentricular ArrhythmiaMedication EffectPacemaker VVIPacemaker DDD [/group] Cardiology Consultation We offer in office consultation as well as virtual in home consultation via telemedicine, and we'll schedule the appropriate venue with the patient. Book Consultation Additional Comments Please add any additional comments below. Referring/Supervising Physician Signature Please use your mouse or touch to sign in the box below.
