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Kidney Bladder Prostate Other Chronic Kidney Disease Hypertension Kidney Stones Hematuria Proteinuria Gastroscopy Colonoscopy Gallbladder Hernia Breast Ano-Rectal Other Aorta Arterial 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: 416-840-8434 FOR 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 Electrophysiology Toronto 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 Disease Aortic Aneurysm Carotid Disease Varicose Veins Referring Physician (Print): NEPHROLOGY & HYPERTENSION Other Patient Name: DOB: F Health card: Tel: M Please affix label here. MULTIDISCIPLINARY TEAM Dr. Ram Aggarwal Medical Director CARDIOLOGY GROUP (ECPG) Dr. Lee Daba Director of Cardiology Dr. Ram Aggarwal Dr. Vini Kunanithy INTERVENTIONAL CARDIOLOGY Dr. Dominic Raco Corporate Chief of Cardiology William Osler Health System CARDIOVASCULAR SURGERY CLINIC Dr. Vivek Rao Chief of Cardiac Surgery Toronto General Hospital Dr. Maral Ouzounian Dr. Mitesh Badiwala NUCLEAR CARDIOLOGY Dr. Lee Daba Dr. Mark Iwanochko VASCULAR SURGERY Dr. Al Lossing Southlake Health Centre Dr. Leonard Tse Dr. Varun Kapila DIABETES & ENDOCRINOLOGY Dr. Laura Rothman NEPHROLOGY & HYPERTENSION Dr. Christina Kim ALLERGY & IMMUNOLOGY Dr. Jaclyn Quirt UROLOGY Dr. Rajiv Gupta INFECTIOUS DISEASE Dr. Mahin Baqi RESPIROLOGY Dr. Mike Miletin PFT Lab Director Dr. Kevin Lumb GENERAL SURGERY Dr. 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/event 24 hr Ambulatory BP monitoring (Note $50 charge to patient) MUGA Scan for Ventricular Function - Ejection Fraction Myocardial Perfusion Imaging STAT Examination CONSULTATION REFERRAL FORM

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  • 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