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Your specific question or concern:

Allergies/Adverse reactions:

Suitable referrals for tele-consultation: ● For advice on how to triage, diagnose or treat your patient's potential cardiac symptoms. ● If you are uncertain about the suitability of your patient for a formal face-to-face cardiology consultation. ● For advice on the appropriate cardio-diagnostic test for your patient. ● If you would like to discuss the results of your patient’s cardiac tests or procedures. ● If you require a more urgent cardio-diagnostic test or consultation for your patient than was offered.

Current medications:

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Primary care MD Name:

Name:Last Name:

First Name:

PHN: Gender:

Phone:

Specialty:

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PRACID:

MD signature and Clinic Name / STAMP (Required)

Please select the day(s) of the week and time of day you are available:

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Relevant past medical history:

Date of referral: mm/dd/yyyy

Patient Demographics Referring Information

Tele-Consultation Requisition

To Book an Appointment:

Fax: (403) 571-6990 Phone: (403) 571-8641

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