Kidney Bladder Prostate Other
Chronic Kidney Disease Hypertension Kidney Stones Hematuria Proteinuria
Gastroscopy Colonoscopy Gallbladder Hernia Breast Ano-Rectal Other
AortaArterial Arms Legs Venous Arms (DVT) Legs (DVT)Other
Dyspnea SOB (NYD) Asthma / COPD
Other
Pulmonary Function Testing (complete)Exercise Oximetry / 6 Minute Walk Test
Type 1 Diabetes Type 2 Diabetes Osteoporosis Lipids / Cholesterol Thyroid Other
VASCULAR
PULMONARY
DIABETES & ENDOCRINOLOGY
Carotid & Vertebral Vascular Screen
Please fax referrals, along with all relevant notes, labs, and test results to the central booking line: 416-840-8434FOR STAT OR URGENT REFERRALS, PLEASE CALL 416-297-8362, THEN PRESS OPTION 4
Allergic rhinitis Asthma Drug allergy Stinging insect allergy Immunodeficiency
Urticaria and angioedema Food allergy Eczema Other
ALLERGY & IMMUNOLOGY
UROLOGY
INFECTIOUS DISEASE
TB HIV Other
Reason for Referral Diagnostic Tests
Reason for Referral Diagnostic Tests
GENERAL SURGERY & ENDOSCOPY
DIABETES EDUCATION CLINIC
Diabetes Type: Duration: Co-Morbidities:
Dr. Edyta Dudzic
HEART RHYTHM CLINIC
Dr. K . Nanthakumar Chief of ElectrophysiologyToronto General Hospital
OHIP Provider ID #:
Physician Signature:
Copy to:
Physician Name:
Fax:
6175 Hwy # 7 Units 19 - 22 Vaughan, ON L4H 0P6 Tel: 416.297.8362 Fax: 416.840.8434
Peripheral Vascular DiseaseAortic Aneurysm
Carotid DiseaseVaricose Veins
Referring Physician (Print):
NEPHROLOGY & HYPERTENSION
Other
Patient Name:
DOB: F
Health card:
Tel:
M
Please affix label here.
MULTIDISCIPLINARY TEAM
Dr. Ram AggarwalMedical Director
CARDIOLOGY GROUP (ECPG)
Dr. Lee DabaDirector of Cardiology
Dr. Ram AggarwalDr. Vini Kunanithy
INTERVENTIONALCARDIOLOGY
Dr. Dominic RacoCorporate Chief of CardiologyWilliam Osler Health System
CARDIOVASCULAR SURGERY CLINIC
Dr. Vivek Rao Chief of Cardiac SurgeryToronto General Hospital
Dr. Maral Ouzounian Dr. Mitesh Badiwala
NUCLEAR CARDIOLOGY
Dr. Lee Daba Dr. Mark Iwanochko
VASCULAR SURGERY
Dr. Al LossingSouthlake Health Centre
Dr. Leonard TseDr. Varun Kapila
DIABETES & ENDOCRINOLOGYDr. Laura Rothman
NEPHROLOGY & HYPERTENSIONDr. Christina Kim
ALLERGY & IMMUNOLOGYDr. Jaclyn Quirt
UROLOGYDr. Rajiv Gupta
INFECTIOUS DISEASEDr. Mahin Baqi
RESPIROLOGY
Dr. Mike MiletinPFT Lab DirectorDr. Kevin Lumb
GENERAL SURGERYDr. Zane Jackson
CARDIOLOGY
Clinical History:
Reason for Referral Diagnostic Tests
Consultation & Diagnostic Testing Diagnostic Testing ONLY
*All consultations will be triaged to the first available specialist to decrease wait times.
*Please note select diagnostic tests will be performed that are deemed necessary to address the clinical reason for referral.
Arrhythmia, Palpitations
Dizziness / Syncope
Murmur / Valve Disease
CAD / MI / PCI / CABG
Other
Abnormal ECG
Chest pain
CHF
Dyspnea / SOB
Exercise Persantine
Holter Monitoring
2-D Echocardiogram Stress test (GXT) Stress - Echo
48 hr 72 hr 14 day holter/event24 hr Ambulatory BP monitoring (Note $50 charge to patient)
MUGA Scan for Ventricular Function - Ejection Fraction
Myocardial Perfusion Imaging
STAT Examination
CONSULTATION REFERRAL FORM
Diagnostic Testing ONLY STAT Examination
N
427
407
50 27
7
400
IHCC -VDMC
Esso
Steeles Ave.
Finch Ave.
HolidayInnQueen St. E.
H EtobicokeGeneralHospital
7
6175 Hwy 7Units 19 -22
GETTING HERE: From Brampton:
Take preferred route toward Highway 7/Queen Street East and take the 501/501A Zm Queen bus eastbound to Gore Road.
Transfer* onto the YRT #77/77A (Highway 7) bus and take it to Highway 7 and Vaughan Valley Blvd. (stop #5691).
Walk forward and cross the street toward the plaza directly across the RBC Bank / McDonalds / Swiss Chalet.
*Brampton transfers are accepted on YRT buses.
From Vaughan:
Take preferred route toward Highway 7 and take the YRT #77/77A (Highway 7) bus westbound to Highway 7 and Vaughan Valley Blvd. (stop #4141).
Cross the street toward the plaza directly across the RBC Bank / McDonalds / Swiss Chalet. From William Osler Health Centre (Etobicoke General Hospital):
Walk toward the northwest corner of Highway 27 and Humber College Blvd. (the bus stop is behind the houses [stop #5119]).
Take the YRT#7 (Martin Grove) bus northbound to Martin Grove Rd & Highway 7 (stop #3525).
Cross the street and transfer onto the YRT #77/77A (Highway 7) bus westbound to Highway 7 and Vaughan Valley Blvd. (stop #4141).
Cross the street toward the plaza directly across the RBC Bank / McDonalds / Swiss Chalet.
This requisition form can be taken to any licensed facility providing healthcare services including hospitals and IHFs.
Patient Preparation Instructions
Please bring a list of current medications to your appointment
ULTRASOUND
Vascular Screen / Aorta UltrasoundWe require that you have an empty stomachNo eating or drinking 8 hours prior to the appointment
All other Vascular Ultrasound & 2-D Echocardiogram (Non-Stress):No restrictions on food or drinkNo preparation required
Stress EchocardiogramWear comfortable shoes and clothing(Please do not wear a one-piece garment)
Exercise Treadmill Stress Test (GXT)Wear comfortable shoes and clothing Women should wear a bra preferably with no underwire Do not wear a one-piece garment
Nuclear CardiologyThis test takes approximately 2 - 4 hours and you will receive anintravenous injection Wear comfortable shoes and clothing for the exercise stress test Women should wear a bra preferably with no underwire Do not wear a one-piece garment NO CAFFEINE 24 hours prior to the test
No Tylenol 2s or 3s for at least 48 hours prior to the test Do not smoke for 2 hours before the test Have only a light breakfast on the day of the test (toast and juice) and then no food or drink 4 hours prior to the test (2 hours if you're a diabetic) Water is allowed Bring something to eat during the test Bring a list of current medications Do not apply cream, lotion, or powder to your skin
Myocardial Perfusion Imaging (Exercise)Discontinue beta blockers 48 hours prior to the exam with your doctors approvalInsulin-dependent diabetic patients should take their insulin with a light meal 3 hours prior to the exam
Myocardial Perfusion Imaging (Persantine)Discontinue theophylline derivatives 48 hours prior to the exam with your doctors approval Insulin-dependent diabetic patients should take their insulin with a light meal 3 hours prior to the exam
Pulmonary Function TestPlease avoid smoking on the day of your testDo not use bronchodilators on the day of your testPlease bring a list of current medications
Please remember to bring your Health Card and this requisition signed by a registered physician
If you would like to cancel / change your appointment, please notify our office at least 24 hours prior to your scheduled time
Refrain from any coffee, tea, soft drinks, chocolate beverages, energy drinks (even the decaffeinated varieties)
Consult with your physician if it is ok to discontinue Beta-Blockers(Bisoprolol, Metoprolol, etc.) 48 hours prior to your exam
Consult with your physician if it is ok to discontinue Calcium Channel Blockers (Diltiazem, Verapamil, etc.) 24 hours prior to your exam
