Download COMPREHENSIVE CARDIOLOGY NUCLEAR

Clear Form
Print Form
COMPREHENSIVE CARDIOLOGY
NUCLEAR CARDIOLOGY
1849 YONGE STREET, SUITE 218
TORONTO, ON M4S 1Y2
TEL: 416-928-3467 | FAX: 416-928-3502
PATIENT INFORMATION:
PATIENT’S NAME: ____________________________________________ D.O.B: __________________
F
M
ADDRESS: ________________________________________________________________________________________
TELEPHONE #: ___________________________________ OHIP #: __________________________________________
APPOINTMENT DATE: _____________________________ TIME: ________________________ WEIGHT: ___________
*Note: Please see back for patient instructions and directions.
Check if applicable
STAT
NUCLEAR CARDIOLOGY
CARDIOLOGISTS
Dr. Brian Gilbert
MYOCARDIAL PERFUSION IMAGING - MPI
Staff Cardiologist, Schulich Heart Program,
Sunnybrook Health Sciences Centre & Professor
Medicine, University of Toronto.
(CARDIOLITE / MYOVIEW)
Dr. Christopher Morgan
Erectile Dysfunction (48hrs), and Calcium Blockers (24hrs) prior to cardiac stressing.
Staff Cardiologist, Schulich Heart Program,
Sunnybrook Health Sciences Centre & Associate
Professor Medicine, University of Toronto. Testamur,
American Society of Echocardiography.
Dr. Shaheeda Ahmed
Staff Cardiologist, Schulich Heart Program,
Sunnybrook Health Sciences Centre & Assistant
Professor of Medicine, University of Toronto. SiteDirector – Cardiology Fellowship Program, Schulich
Heart Centre, Sunnybrook Health Sciences Centre.
(if unable to exercise)
*Note: Please consult your doctor regarding discontinuation of Beta Blockers (48hrs),
CARDIOLOGY
Exercise Test Only (GXT)
indications:
Dr. Vijay Chauhan
Staff Electrophysiologist, Peter Munk Cardiac Centre.
Expertise in Cardiac Arrhythmias, Pacemakers,
Defibrillators. Associate Professor of Medicine,
University of Toronto.
Dr. Luis Noronha
Cardiology Diagnostic and Treatment Center,
Diabetes & Hypertension Unit.
Chest pain suspicious of CAD
Murmur
Hypertension
Palpitations/arrhythmias
Syncope
Congestive heart failure
Other __________________________
Staff Cardiologist, Schulich Heart Program,
Sunnybrook Health Sciences Centre & Subspecialty
in Non-Invasive Cardiac Imaging & Assistant
Professor of Medicine, University of Toronto.
Staff Cardiologist, Schulich Heart Program,
Sunnybrook Health Sciences Centre. Expertise in
Cardiac Catheterization and Percutaneous Coronary
Interventions & Assistant Professor of Medicine,
University of Toronto.
Stress Echo
Echocardiogram (Colour Doppler) Please select one of the following
Dr. Mark Hansen
Dr. Mina Madan
Exercise
Persantine
AMBULATORY MONITORING
Holter Monitoring
24 Hours
2 Weeks
48 Hours
1 Month
72 Hours
LOOP / Cardiac Event (2 Weeks)
1 Week
24 Hr Ambulatory BP Monitor ($80)
CARDIOLOGY CONSULTATION
Cardiology Consultation Requested
Cardiology Consultation requested (if test result is positive/ abnormal)
• Atrial Fibrillation/ Arrhythmias
• Heart Failure/ Dyspnea
• Hypertension
• Angina/ Ischemic Heart Disease
• Valvular Heart Disease
• General Cardiology
• Cardiac Risk Assessment
PATIENT HISTORY:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
REFERRING PHYSICIAN INFORMATION:
COPY TO:
PHYSICIAN’S NAME: ________________________________ PHYSICIAN’S NAME: ____________________________
BILLING #: ________________________________________
PHYSICIAN’S PHONE #: _________________________
TEL/FAX #: ________________________________________
PHYSICIAN’S FAX #: ____________________________
PHYSICIAN’S SIGNATURE: ___________________________
PATIENT INSTRUCTIONS
NOTE:
A valid health card must be shown at every visit.
A signed requisition by a registered physician is mandatory for all exams
If you would like to cancel/ change your appointment, please notify our office at least 24 hours
prior to your scheduled time.
For additional locations across Ontario, visit www.myhealthcentre.ca
NUCLEAR CARDIOLOGY PREPARATIONS AND INSTRUCTIONS
1. Nothing to eat 4 hours before the test. (Patient may have a light breakfast 4 hours prior to the test).
2. For PERSANTINE MPI only; discontinue all caffeine compounds, including decaffeinated varieties and all kinds of tea
(coffee, tea, chocolate, pop, Tylenol 2&3) 24 hours prior to the test. Patient can come in regular clothes.
Insulin-dependent diabetics should take their insulin and a light meal 3-4 hours prior to the test.
3. For EXERCISE MPI and GXT; discontinue caffeine products (coffee, tea, pop, etc) at least 4 hours prior to the test.
Bring comfortable shoes, T-shirt and pants/shorts for exercise test.
4. Bring a list of prescriptions and medications you are taking.
5. Check with your physician, if it is OK to discontinue Beta-Blockers (e.g. Atenolol, Metoprolol) for 48 hrs, as well as
Calcium Channel Blockers (e.g. Diltiazem and Verapamil) 24 hours prior to the test.
The MYOCARDIAL PERFUSION IMAGING consists of 2 parts. 1. Stress Study: The stress study takes approximately 22.5 hours and consists of stress test, injection and imaging. 2. Rest Study: This study can take approximately 1.5 -2.0
hours and consists of an injection at rest followed by imaging.
The clinic is located at 1849 Yonge Street,
second floor in Suite 218.
The major intersection is Yonge and Davisville.
We are just one and a half blocks South of
Davisville.
P
This requisition form can be taken to any licensed facility providing healthcare services including hospitals and IHFs,
such as those listed on the IHF Program. Website: http://www.health.gov.on.ca/en/public/programs/ihf/facilities.aspx