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(416) 630-4757

[email protected]

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

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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 Video or Telemedicine Consult

TESTS REQUIRED

Echocardiogram Stress Echo Treadmill Stress Test 12 Lead ECG 24 HR ABP Monitor (not covered by OHIP) 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

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