Ks imaging refferal -Form

Patient Name
Date of Birth

MonthDayYear
Date
Phone
Patient Address
Health Card
Referring Physician
Results Call
or Fax
Current Complaint / Patient History
Indication
Cardiac testing requested
Reason for Referral / Cardiac Testing

Presyncope / Syncope Hypertension

ABPM (24hr Ambulatory BP Monitor)

Electrocardiogram Echocardiogram

Dobutamine Stress Echo Patients unable to exercise Exercise Stress Echo with Contrast

Sprirometry - with Flow/Volume Loop

Post Bronchodilator Post-exercise

Dr. Hisham Dokainish, MD FRCPC FACC FASE "Cardology, Adult

Cardiac and Vascular Clinic Pounds for Health Clinic "Weight loss management (OHIP funded)

Diabetes & Vascular Health Clinic Memory Clinic "For, patent wthknownorsuspectedcognitive dystunctior

Stroke Prevention Clinic Bone Health Clinic "Osteoporosis
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