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Print Form Email to KMH 236 Avenue Road Toronto, ON M5R 2J4 Tel.: (905) 855-1320 Fax: (289) 373-3031 CARDIOLOGY CLINIC URGENT REFERRAL FORM Circle if applicable PATIENT NAME: _____________________________________ PATIENT ADDRESS: __________________________________ 1. Please complete form and fax to 289-373-3031 __________________________________ PATIENT PHONE #: __________________________________ 2. See back for patient PATIENT OHIP #: _____________________DOB:___________ instructions and map APPOINTMENT DATE: ________________TIME:___________ HISTORY ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ CONSULTS 74. 75. 77. 154. 167. No Preference – Earliest Appointment A. Grover, M.D., F.R.C.P. (C), F.A.C.C. R. Myers, M.D., F.R.C.P. (C), F.A.C.C. S. Gottlieb, M.D., F.A.C.C. S. Bhatia, M.D./M.B.A., F.R.C.P. (C) CARDIOVASCULAR SURGERY CONSULTS 78. 79. G. Christakis, M.D., F.R.C.S.(C) G. Cohen, M.D., M.Sc., Ph.D., F.R.C.S.(C) CARDIOLOGY 7. EXERCISE TEST ONLY (GXT) 8. AMBULATORY BLOOD PRESSURE MONITOR 9. 24 Hrs. HOLTER MONITOR 11. 10. 48 Hrs. HOLTER MONITOR 155. 86. LOOP/CARDIAC EVENT MONITOR ECHOCARDIOGRAPHY STRESS ECHO NUCLEAR CARDIOLOGY MYOCARDIAL PERFUSION (CARDIOLITE/SESTAMIBI) 1. ❑ EXERCISE SE 2. ❑ PERSANTINE 81. ❑ DOBUTAMINE VENTRICULAR FUNCTION (MUGA) 4. ❑ PERSANTINE 5 82. ❑ DOBUTAMINE D VIABILITY STUDY (THALLIUM) 69. ❑ REST REST N NOTE: Please inform patient regarding the discontinuation of Beta blockers, Calcium blockers and erectile dysfunction medications 48 hours prior to test. ❑ Cardiology Consult, if test result is positive/abnormal. Date: CC Physician: REFERRING PHYSICIAN INFORMATION Billing # Referring Physician Signature: Billing #: Referring Physician Stamp: NUCLEAR CARDIOLOGY PATIENT INSTRUCTIONS 1.1. 2. or lighton lunch and of then eat or drink (except sipsdecaffeinated of water for A light breakfast breakfast/lunch the day thenothing test. Notocaffeine (No tea, coffee, products, chocolate, sodaprior pop to or the medications caffeine). medications) for 2 hours study. Nocontaining caffeine for 12 hours prior to the study (No tea, coffee, decaffeinated products, chocolate, soda pop or medications containing Bring comfortable shoes, t-shirt and pants or shorts for exercise tests. caffeine). 3. 2. Bring all current prescription medications, and check with your physician regarding the Bring comfortable shoes, t-shirt and pants or shorts for exercise tests. discontinuation of any heart or erectile dysfunction medications. 3.4. Bring all current prescription medications, checkThe withfirst your physician the The Spect Cardiolite protocol consists ofand 2 parts. portion lasts regarding approximately discontinuation of any heart or erectile dysfunction medications. 2-3 hours and consists of imaging followed by a stress test. The patient will then wait 45-60 minutes before additional imaging which takes about 30 minutes. The Spect Cardiolite protocol consists of 2 parts. The first portion lasts approximately 2-3 and consists of imaging followed a stress will lasts then about wait The hours Persantine Ventricular Function study by consists of test. one The part patient only and 45-60 minutes before additional imaging which takes about 30 minutes. 1.5 hours. 4. 5. 5. The Dobutamine Ventricular Function study consists of one part only and lasts about 1.5 hours.