IHI Toronto Cardio Form - KMH Labs

MD/MBA, FRCPC
Toronto
MD, CM, FRCPC
Markham
MD, FRCPC
Mississauga
MD, FRCPC, FACC
Kitchener-Waterloo
MD, FACC
Toronto
MD, FRCPC, FACC
Mississauga, Toronto
MD, FACC, FSCAI
Kitchener-Waterloo,
Mississauga, Hamilton
MD, FRCPC, FACC
North York, Toronto
Ruben Rajakumar
FRCPC, FACC
Cardiologist
MD, FACC
Markham, Scarborough
No preference.
Earliest Appointment.
INTERNAL MEDICINE
CONSULT TEAM
Joe Heng Lai
MSc, MD, FRCPC
Mississauga
Specializing in patients with CHF,
hypertension, diabetes, stroke prevention,
gastrointestinal diseases, hematology
(including coagulopathy disorders),
rheumatology, endocrinology,
and COPD/asthma.
PATIENT NAME: _____________________________________
PATIENT ADDRESS: __________________________________
__________________________________
PATIENT PHONE #: __________________________________
PATIENT OHIP #: _____________________DOB:___________
APPOINTMENT DATE: ________________TIME:___________
236 Avenue Road
Toronto, Ontario M5R 2J4
55 Town Centre Court, Suite 109
Scarborough, Ontario M1P 4X4
1. EXERCISE
2. PERSANTINE
81. DOBUTAMINE
Date:
Billing number:
CC Physician:
CARDIOLOGY CONSULT
7. GRADED EXERCISE TEST
(GXT)
8. AMBULATORY BLOOD
PRESSURE MONITOR ($65)
9. 24 Hrs. HOLTER MONITOR
REFERRAL FORM
2075 Hadwen Road
Mississauga, Ontario L5K 2L3
206 James Street South, Suite 104
Hamilton, Ontario L8P 3A9
50 Minthorn Blvd., Suite 101
Markham, Ontario L3T 7X8
Burlington Professional Centre
3155 Harvester Road, Suite 106
Burlington, Ontario L7N 3V2
1. Please complete form
and fax to 289-373-3031
2. See back for patient
instructions and map
4. PERSANTINE
82. DOBUTAMINE
69. REST
10. 48 Hrs. HOLTER MONITOR
86. LOOP/CARDIAC EVENT
MONITOR (two weeks)
Referring Physician Signature:
Referring Physician Stamp:
Tel.: (905) 855-1320
Toll Free: 1-877-564-5227
Fax: (289) 373-3031
11.
1310 Don Mills Road, Suite 5
North York, Ontario M3B 2W6
751-B Victoria Street S.,
Suite108
Kitchener, Ontario N2M 5N4
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
PHYSICIAN’S NOTE: Please inform the patient regarding the discontinuation of Beta blockers, Calcium blockers and eretile dysfunction medications 48 hours prior to test.
ECHOCARDIOGRAPHY
155. STRESS ECHO
174. CAROTID ULTRASOUND
(in Mississauga only)
07/12

Maps Not
to Scale
BRANT ST.
BRIMLEY RD.
HAMILTON QEW TORONTO
FAIRVIEW ST.
GUELPH LINE
SHEPPARD AVE.
HWY 401
PROGRESS AVE.
HARVESTER RD.
Burlington
Mall
SCARBOROUGH
TWON CENTRE
TOWN CENTER
BOROUGH DR.
TOWN
ELLESMERE RD.
LAWRENCE AVE.
SOUTH SERVICE RD.
Burlington
Professional
Centre
TRIZEC GT
CENTRE CT.
PROGRESS AVE.
SCARBOROUGH
McCOWAN RD.
McCOWAN
SUBWAY
NUCLEAR CARDIOLOGY PATIENT INSTRUCTIONS
WALKERS LINE
MARKHAM RD.
403 W
MACNAB
BOLD ST.
DUKE ST.
ROBINSON ST.
BAYVIEW AVE.
401
KMH
KMH
407
HWY 7
JOHN ST.
LESLIE ST.
LESLIE ST.
JAMES ST. SOUTH
MINTHORN
BLVD
DON MILLS
MAIN ST. EAST
AUGUSTA ST.
YOUNG ST.
FOREST AVE.
CHARLTON ST.
ST. JOSEPH’S
HOSPITAL
407
STEELES AVE. E.
404
404 404
DVP
HUGHSON
WOODBINE
HAYMARKET ST.
1. 1. A light breakfast/lunch breakfast or light on lunch the day and of then the nothing test. No to caffeine eat or drink (No tea, (except coffee, sips decaffeinated
of water for
products, medications) chocolate, for 2 hours soda prior pop or to medications the study. No containing caffeine for caffeine). 12 hours prior to the study
(No tea, coffee, decaffeinated products, chocolate, soda pop or medications containing
2. Bring caffeine). comfortable shoes, t-shirt and pants or shorts for exercise tests.
3. Bring all current prescription medications, and check with your physician regarding the
2. Bring comfortable shoes, t-shirt and pants or shorts for exercise tests.
discontinuation of any heart or erectile dysfunction medications.
3. 4. The Bring Spect all current Cardiolite prescription protocol medications, consists of and 2 parts. check The with first your portion physician lasts approximately
regarding
2-3 the hours discontinuation and consists of any of heart imaging or erectile followed dysfunction by a stress medications. test. The patient will then wait
45-60 minutes before additional imaging which takes about 30 minutes.
4. The Spect Cardiolite protocol consists of 2 parts. The first portion lasts approximately
5. The 2-3 hours Persantine and consists Ventricular of imaging Function followed study by consists a stress of test. one The part patient only and will lasts then about wait
1.5 45-60 hours. minutes before additional imaging which takes about 30 minutes.
5. The Dobutamine Ventricular Function study consists of one part only and lasts about
1.5 hours.
HWY 7
407
401