Referral Form – Healthy Heart Centre

Urgent Care 24h

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Urgent Care 24h

Kindly Select Your Location to download the referral form

MILTON

SCARBOROUGH

Kindly Select Your Location

MILTON

SCARBOROUGH

TO BOOK AN APPOINTMENT CALL : 905-636-9900

*If you need to re-schedule your appointment, please call us at least 24 hours in advance so that we can accommodate other patients if necessary.

Patient Information

Referring Physician

First Name

Referring MD

LAST NAME

Signature

OHIP No

Billing No

DOB

Address

Address

Fax No:

Tel No :

Tests

CARDIOLOGY CONSULTATION INTERNAL MEDICINE CONSULTATION ECHOCARDIOGRAPHY STRESS ECHO STRESS TEST RESTING ECG HOLTER 48 HRS HOLTER 72 HRS CHF / HTN (ECG/ECHO) CHEST PAIN / CAD (ECHO / ECG / STRESS ECHO) ARRHYTHMIA (ECG/ECHO/72 HRS HOLTER) AMBULATORY BLOOD PRESSURE MONITOR ($65) CONTINOUS RECORDERS 1 WEEK CONTINOUS RECORDERS 2 WEEK NUCLEAR CARDIOLOGY LOOP / CARDIAC EVENT MONITOR

IF TEST IS ABNORMAL PLEASE ARRANGE FOR A CONSULTATION PRE OR POST EVALUATION

PCI DEVICE PLACEMENT EP PROCEDURES SURGERY

REASON FOR TEST

PALPITATION CHEST PAIN SOB ABNORMAL ECG CHF ARRHYTHMIA STROKE / TIA PAD MI VALVULAR DISEASE HEART MURMUR PERIPHERAL EDEMA HYPOTENSION HTN SYNCOPE / DIZZINESS ENDOCARDITS AORTIC DISSECTION PULMONARY HYPERTENSION

MODERATE TO HIGH RISK PROGRAM

AGE FAMILY HISTORY ETHENICITY DIABETES MELLITUS HYPERTENSION SMOKING HISTORY OBESITY SEDENTARY LIFESTYLE HIGH STRESS DYSLIPIDEMIA POOR DIET METABOLIC SYNDROME

PATIENT INFORMATION

FUL NAME

OHIP NO

DOB

Address

Tel No:

REFERRING PHYSICIAN

Refering MD

Signature

Billing No

Address

Fax No :

Tests

CARDIOLOGY CONSULTATION INTERNAL MEDICINE CONSULTATION ECHOCARDIOGRAPHY STRESS ECHO STRESS TEST RESTING ECG HOLTER 48 HRS HOLTER 72 HRS CHF / HTN (ECG/ECHO) CHEST PAIN / CAD (ECHO / ECG / STRESS ECHO) ARRHYTHMIA (ECG/ECHO/72 HRS HOLTER) AMBULATORY BLOOD PRESSURE MONITOR ($65) CONTINOUS RECORDERS 1 WEEK CONTINOUS RECORDERS 2 WEEK NUCLEAR CARDIOLOGY LOOP / CARDIAC EVENT MONITOR

IF TEST IS ABNORMAL PLEASE ARRANGE FOR A CONSULTATION PRE OR POST EVALUATION

PCI DEVICE PLACEMENT EP PROCEDURES SURGERY

REASON FOR TEST

PALPITATION CHEST PAIN SOB ABNORMAL ECG CHF ARRHYTHMIA STROKE / TIA PAD MI VALVULAR DISEASE HEART MURMUR PERIPHERAL EDEMA HYPOTENSION HTN SYNCOPE / DIZZINESS ENDOCARDITS AORTIC DISSECTION PULMONARY HYPERTENSION

MODERATE TO HIGH RISK PROGRAM

AGE FAMILY HISTORY ETHENICITY DIABETES MELLITUS HYPERTENSION SMOKING HISTORY OBESITY SEDENTARY LIFESTYLE HIGH STRESS DYSLIPIDEMIA POOR DIET METABOLIC SYNDROME

TO BOOK AN APPOINTMENT CALL : 905-636-9900

*If you need to re-schedule your appointment, please call us at least 24 hours in advance so that we can accommodate other patients if necessary.

Patient Information

Referring Physician

First NAME

Referring MD

Last NAME

Signature

OHIP NO

Billing No

DOB

Address

Address

Fax No :

Fax No:

Tests

CARDIOLOGY CONSULTATION INTERNAL MEDICINE CONSULTATION ECHOCARDIOGRAPHY STRESS ECHO STRESS TEST RESTING ECG HOLTER 48 HRS HOLTER 72 HRS PULMONARY FUNCTION TEST CHF / HTN (ECG/ECHO) CHEST PAIN / CAD (ECHO / ECG / STRESS ECHO) ARRHYTHMIA (ECG/ECHO/72 HRS HOLTER) AMBULATORY BLOOD PRESSURE MONITOR ($65) CONTINOUS RECORDERS 1 WEEK CONTINOUS RECORDERS 2 WEEK NUCLEAR CARDIOLOGY LOOP/CARDIAC EVENT MONITOR

IF TEST IS ABNORMAL PLEASE ARRANGE FOR A CONSULTATION PRE OR POST EVALUATION

PCI DEVICE PLACEMENT EP PROCEDURES SURGERY

REASON FOR TEST

PALPITATION CHEST PAIN SOB ABNORMAL ECG CHF ARRHYTHMIA STROKE / TIA PAD MI VALVULAR DISEASE HEART MURMUR PERIPHERAL EDEMA HYPOTENSION HTN SYNCOPE / DIZZINESS ENDOCARDITS AORTIC DISSECTION PULMONARY HYPERTENSION

MODERATE TO HIGH RISK PROGRAM

AGE FAMILY HISTORY ETHENICITY DIABETES MELLITUS HYPERTENSION SMOKING HISTORY OBESITY SEDENTARY LIFESTYLE HIGH STRESS DYSLIPIDEMIA POOR DIET METABOLIC SYNDROME

PATIENT INFORMATION

FUL NAME

OHIP NO

DOB

Address

Tel No:

REFERRING PHYSICIAN

Referring MD

Signature

Billing No

Address

Fax No :

Tests

CARDIOLOGY CONSULTATION INTERNAL MEDICINE CONSULTATION ECHOCARDIOGRAPHY STRESS ECHO STRESS TEST RESTING ECG HOLTER 48 HRS HOLTER 72 HRS PULMONARY FUNCTION TEST CHF / HTN (ECG/ECHO) CHEST PAIN / CAD (ECHO / ECG / STRESS ECHO) ARRHYTHMIA (ECG/ECHO/72 HRS HOLTER) AMBULATORY BLOOD PRESSURE MONITOR ($65) CONTINOUS RECORDERS 1 WEEK CONTINOUS RECORDERS 2 WEEK NUCLEAR CARDIOLOGY LOOP / CARDIAC EVENT MONITOR

IF TEST IS ABNORMAL PLEASE ARRANGE FOR A CONSULTATION PRE OR POST EVALUATION

PCI DEVICE PLACEMENT EP PROCEDURES SURGERY

REASON FOR TEST

PALPITATION CHEST PAIN SOB ABNORMAL ECG CHF ARRHYTHMIA STROKE / TIA PAD MI VALVULAR DISEASE HEART MURMUR PERIPHERAL EDEMA HYPOTENSION HTN SYNCOPE / DIZZINESS ENDOCARDITS AORTIC DISSECTION PULMONARY HYPERTENSION

MODERATE TO HIGH RISK PROGRAM

AGE FAMILY HISTORY ETHENICITY DIABETES MELLITUS HYPERTENSION SMOKING HISTORY OBESITY SEDENTARY LIFESTYLE HIGH STRESS DYSLIPIDEMIA POOR DIET METABOLIC SYNDROME

Healthy Heart Centre is your solutions partner. Whether you are a general physician or a specialist, at Healthy Heart Centre we pride ourselves in doing things differently to enhance your practice. We are not about staying ahead of the curve, but more about defining the curve.

416 286 4442

Request an Appointment

Services

Cardiac Consultation.
Electrocardiogram (ECG).
Ambulatory Blood Pressure.
Holter Monitoring.
Pulmonary Function Test.
Stress Echo.
Exercise Stress Test.

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225-1333 Neilson Road, Toronto, ON, M1B 4Y9
16-348 Bronte Street S., Milton, ON, L9T 0H7
416 286 4442
info@healthyheartcentre.ca

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