Online Referral Form

Reason for Referral *
LOCATIONS
Please select a location:*

Toronto - 4040 Finch Ave E, suite 404Scarborough - 385 Silver Star Blvd, suite 113Richmond Hill - 9425 Leslie St, Unit 14Fergus - 6420 Beatty Line N, unit 205Carleton Place - 355 Franktown Rd, Carleton Place unit 13Ottawa - 4289 Innes RoadBelleville - 231 Front StreetBolton - 12706 Hwy 50, Unit 101Guelph - 812 Woolwich StreetMississuaga - Coming soonMarkham - Coming soonGuelph - Coming soon 2nd locationHamilton - Coming soon
Patient information:
FIRST NAME*
LAST NAME*
DATE OF BIRTH*

MonthDayYear
Date
Gender*

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 in Ocean E-referral Portal**
Should be Empty:

LOCATIONS

Patient information:

Cardiology Procedures

CLINICAL INFORMATION