Download KMH Nuclear Cardio Req

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.