Patient Referral Form

PATIENT INFORMATION / LABEL

CARDIAC INVESTIGATIONS

LastName:

FirstName:

Postal Code

Work

Date of Birth ( dd / mm / yyyy ) :

Phone (home)

Health Card #

2D ECHO AND COLOUR DOPPLER12 LEAD ECGHOLTER MONITORING 3 DAYS 14 DAYS

24 HOUR AMBULATORY BLOOD PRESSURE MONITORING (NOT COVERED BY OHIP)

Sex: M F

City

Address

VC

/ /

● DISCONTINUATION OF BETA BLOCKERS AND CALCIUM BLOCKERS IMPROVES THE DIAGNOSTIC ACCURACY OF EXERCISETESTS, BUT SHOULD ONLY BE DONE ON THE ADVICE OF THE REFERRING PHYSICIAN

● PATIENTS SHOULD BRING THEIR MEDICATIONS AND HEALTH CARDS WITH THEM

Please complete form and fax to: 800-592-7801Cardio Study will contact the patient to schedule appointment.

CARDIOLOGY CONSULT •

PHYSICIAN INFORMATION

Referring Physician: Referring #:

Phone: Fax:

Signature: Date:

CARDIO STUDY OF STRATFORD The Jenny Trout Centre 342 Erie St, Suite 108Stratford, ON N5A 2N4Tel: 800-706-1134 | Fax: 800-592-7801

CLINICAL INFORMATION / INDICATIONS

Dr. A. Crean MD, MRCP(UK)

Dr. T. Vakani MD, FRCP (C)•

• Dr. Z. Sasson MD, FRCP(C)