Home Patient form Cardiology Requisition Form Patient Intake Form (#5)Δ 3780 14th Avenue, Suite 311 and 314,Markham, ON. L3R 4B7 416-503-8282 416-503-1495 admin@aspirecardiology.com Radio Field URGENT ROUTINE Date of Referral:PATIENT INFORMATIONNameGender:OHIP Number:Alternate Phone Number:Date of Birth (MM/DD/YYYY):Address:PhoneEmail:CARDIOLOGY CONSULTATIONRadio Field CONSULT CONSULT, IF TEST RESULTS IS POSITIVE/ABNORMAL CARDIAC DIAGNOSTIC TESTINGEchocardiography 2D Echocardiography Exercise Testing (Treadmill) Stress Test Stress Echocardiography Electrocardiography Holter 48-hour Holter - 72-hour Holter - 7 or 14 Days ECG REASON FOR REFERRALSymptoms Chest Pain Dyspnea Edema Palpitations Presyncope Syncope FatigueClinical Diagnoses and History Atrial Fibrillation/Flutter Ischemic Heart Disease Myocardial Infarction Heart failure Hypertension Dyslipidemia Diabetes Mellitus Abnormal Resting ECG Abnormal Stress Test Abnormal Coronary CT Cardiac masses/thrombus Stroke/TIA Endocarditis Myocarditis Pericarditis Rheumatic Fever CABG/Bypass Angioplasty/Stent Pacemaker or ICD/CRT Cardiomyopathy Valvular heart disease Heart murmur NYD Surgery clearanceOtherReferring Physician:Billing Number:Address:Tel:Fax Number:Completed forms are to be returned via fax: 416-503-1495 or email: admin@aspirecardiology.com Our office will contact the patient directly to schedule an appointment (please attach any relevant/current reports). Submit Form DOWNLOAD PDF
