Skip to content
(416) 630-7540
(416) 630-4757
[email protected]
3695 Keele St Suite 100 North York, ON M3J 1N1
Facebook
Twitter
Linkedin
Main Menu
About
Our Clinic
Testimonials
Associated Clinics
Lawrence Park Cardiology
Covid-19
Services
Areas of Practice
Cardiology Services
Appointments
Make Appointment
Send Referral
Downloadable Referral
Satisfaction Survey
Contact Us
Main Menu
About
Our Clinic
Testimonials
Associated Clinics
Lawrence Park Cardiology
Covid-19
Services
Areas of Practice
Cardiology Services
Appointments
Make Appointment
Send Referral
Downloadable Referral
Satisfaction Survey
Contact Us
3695 Keele St, Toronto, ON M3J 1N
(416) 630-7540
[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 (Cardiology)
Consultation (Internal Medicine)
Hypertension & Cardiac Risk Reduction Clinic (performed at affiliated sites)
Video or Telemedicine Consult
CLINICAL INFO
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
PROVIDERS
First Available
REFERRING PHYSICIAN
PHYSICIAN NAME
OHIP BILLING
PHONE NUMBER
FAX NUMBER
PHYSICIAN EMAIL
SEND REFERRAL