Make an appointment

Skip to content

(416) 630-4757

[email protected]

3695 Keele St Suite 100 North York, ON M3J 1N1

Facebook Twitter Linkedin

Main Menu

About
Covid-19
Services
- Areas of Practice
- Cardiology Services
Appointments
Contact Us

Main Menu

About
Covid-19
Services
- Areas of Practice
- Cardiology Services
Appointments
Contact Us

3695 Keele St, Toronto, ON M3J 1N

[email protected]

PATIENT NAME

ADDRESS

DATE OF BIRTH

GENDER

F M

HEALTH CARD NUMBER

VERSION CODE

EMAIL ADDRESS

HOME PHONE NUMBER

CELL PHONE NUMBER

CLINICAL EVALUATION

Consultation Consult, if abnormal Consultation (Cardiology) Consultation (Internal Medicine) Hypertension & Cardiac Risk Reduction Clinic (performed at affiliated sites) Video or Telemedicine Consult

TESTS REQUIRED

Echocardiogram Stress Echo Treadmill Stress Test 12 Lead ECG 24 HR ABP Monitor - not covered by OHIP (performed at affiliated sites) Exercise Perfusion (performed at affiliated sites) Pharmacologic Perfusion (performed at affiliated sites)

HOLTER MONITOR (Indicate one)

24hr 48hr 72hr 7 days 14 days

REASON FOR VISIT

PROVIDERS

First Available

REFERRING PHYSICIAN

PHYSICIAN NAME

PHYSICIAN NUMBER

PHYSICIAN FAX

PHYSICIAN EMAIL

Copyright 2020. Yorkview Cardiology All Rights Reserved

Facebook Twitter Linkedin