Online Referral Form

PLEASE NOTE: This form is to be only completed by physicians. If you are a patient, please contact us. We do require a referral from your family physician to book an appointment.
Reason for Referral *
LOCATIONS
Please select a location:*

Scarborough - 385 Silver Star Blvd, Suite 113Scarborough - 5928 Finch Ave E Unit 113Fergus - 6420 Beatty Line N, Unit 205Carleton Place - 355 Franktown Rd, Carleton Place Unit 13Belleville - 231 Front StreetFergus - 812 Woolwich StreetGuelph - 649 Scottsdale Dr. Unit 303Stouffville - 37 SandiFord Drive, Unit 107Markham - Coming soonMississuaga - Coming soon
Patient information:
FIRST NAME*
LAST NAME*
DATE OF BIRTH*

MonthDayYear
Date
MaleFemaleOtherPrefer not to respond
HOME PHONE*
MOBILE PHONE*
HEALTH #/Version code*
ADDRESS*
Cardiology Procedures
Choose all that applies:*

Adult ECHOStress Test (GXT)72 hrs. Holter MonitorStress ECHO (*Not available at Carleton & Belleville location*)Persantine/Cardiolite Stress Test (*Not available at Carleton & Belleville location*)7 day Holter Monitor12 Lead ECG24 hrs. Holter Monitor14 day Holter MonitorSaline Study (Stroke)48 hrs. Holter Monitor24 hrs ABP Monitor ($50)
CLINICAL INFORMATION
Clinical Information
Referring MD*
MD Billing #*
Office Phone #*
Office Fax #*
Date

MonthDayYear
DOCTOR CONSULTATION*

First AvailableUrgentDiagnostic OnlyIf test is abnormal please arrange for a consultation
Requests for consultations should include the reason

for referral, medication list, and any previous ECGs,

chest x-rays, blood work, and cardiac assessment.

Please be advised we will send you a fax confirmation with your patient’s appointment date and time.

**All locations are also on Ocean E-referral Portal**
Should be Empty:

PLEASE NOTE: This form is to be only completed by physicians. If you are a patient, please contact us. We do require a referral from your family physician to book an appointment.

LOCATIONS

Patient information:

Cardiology Procedures

CLINICAL INFORMATION