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PEDIATRIC CARDIOLOGY REFERRAL
Contact booking desk at 905-521-2100 x 78517 for any further questions
Please fax completed forms to:
Date of Referral: ___________________________
905-521-5056
Patient Information
Referring Physician Information
Name: ___________________________________________
Name: ____________________________________________
DOB: __________________
Address: ___________________________________________
_____Male
_____Female
Health Card #:________________________________ (OHIP)
Address: ________________________________________
Postal Code: _________________
Telephone: __________________
City: ________________ Postal Code: ________________
Telephone: ______________ Cellular: __________________
Interpreter required: ________________________________
CAS/FACS involvement: ______________________________
Family Physician: ________________________________
Fax: ________________________
Physician Billing #: ________________________________
Signature: ______________________________________
REASON(S) FOR CONSULTATION (Please select all that apply)
□ Murmur
□ Palpitations
□ Suspected cardiac chest pain
□ Syncope with exertion
□ Syncope at rest
□ Pre-syncope
□ SOB/dyspnea
□ Known cardiac disease: __________________________________________
□ Syndromes/Dysmorphisms: ______________________________________
□ Abnormal ECG: _________________________________________________
□ Family Hx of congenital cardiac defects: _____________________________
□ Family Hx of sudden death: _______________________________________
□ Kawasaki: ____________________ Treated with IVIG □ Yes
□ No
□ Other: ________________________________________________________
Details of Referral (frequency of symptoms, other signs and symptoms):
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Medications: _____________________________________________________________________________________
Please select and ATTACH all supporting information and results of tests already completed:
□ Last clinical letter
□ Echocardiogram
□ Blood Work
□ Exercise Test
□ ECG (with tracing)
□ Holter (with tracings)
□ Chest X-ray
□ Other: _________________________________________________________________________________________
PEDIATRIC CARDIOLOGY OFFICE USE ONLY
Cardiologist’s Notes: ________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
□ Echo: ___________________________________
□ Holter: _________________________________
□ EX Test: _________________________________
□ Loop/Event: _____________________________
□ Visit: __________________________________________________________________________________________
□ MN PCARD
□ MNU PCARD
□ MNPCARDFET
Triage Dr.:
□ ALMEIDA
Received: _______________________
□ DILLENBURG
□ MONDAL
Triage Date: __________________________
□ PREDESCU
U#M___________________________