Patient Name:

DOB: F

Health card:

Tel:

Arrhythmia, Palpitations

Dizziness / Syncope

Murmur / Valve Disease

CAD / MI / PCI / CABG

Other

M

Exercise Persantine

CARDIOLOGY

Abnormal ECG

Chest pain

CHF

Dyspnea / SOB Holter Monitoring

PAD AAA Varicose veins Abdominal Aortic Aneurysm Arterial upper limb lower limbVenous upper limb lower limb

TIA / Stroke r/o Carotid StenosisOther

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 ThyroidOther

VASCULAR

Clinical History:

PULMONARY

DIABETES & ENDOCRINOLOGY

2-D Echocardiogram Stress test Stress - Echo

Referring Physician: Billing #:

Fax:Copy to:Signature:Date:

Carotid Doppler

Please fax all relevant notes, labs, and test results.Please fax referrals to the central booking line: 416-840-8434FOR STAT OR URGENT REFERRALS, PLEASE CALL 416-297-8362, THEN PRESS OPTION 4

48 hr 72 hr 14 day holter/event

Allergic rhinitis Asthma Drug allergy Stinging insect allergy Immunodeficiency

Urticaria and angioedema Food allergy Eczema Other

ALLERGY & IMMUNOLOGY

Chronic Kidney Disease Hypertension Kidney Stones Hematuria Proteinuria

NEPHROLOGY & HYPERTENSION

Other

Both R L

Both R L

24 hr Ambulatory BP monitoring (Note $50 charge to patient)

MUGA Scan for Ventricular Function - EF

Myocardial Perfusion Imaging

Reason for Referral Diagnostic Tests

Reason for Referral Diagnostic Tests

Reason for Referral Diagnostic Tests

GENERAL SURGERY & ENDOSCOPY

Gastroscopy Colonoscopy Gallbladder Hernia Breast

Ano-Rectal Local Excision Other

DIABETES EDUCATION CLINIC

Diabetes Type: Duration: Co - Morbidities:

Dr. Edyta Dudzic

HEART RHYTHM CLINIC

Dr. K . Nanthakumar Chief of ElectrophysiologyToronto General Hospital

IHCC Integrated Healthcare CentreVaughan Diagnostic Medical Centre

6175 Hwy # 7 • Units 19 - 22 • Vaughan, ON • L4H 0P6 • Tel: 416.297.8362 • Fax: 416.840.8434

*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.

Please affix label here.

MULTIDISCIPLINARY TEAM

Dr. Ram AggarwalMedical Director

CARDIOLOGY GROUP (ECPG)

Dr. Lee DabaDirector of Cardiology

Dr. Ram Aggarwal

Dr. 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

DIABETES & ENDOCRINOLOGY

Dr. Laura Rothman

NEPHROLOGY & HYPERTENSION

Dr. Christina Kim

ALLERGY & IMMUNOLOGYDr. Jaclyn Quirt

RESPIROLOGY

Dr. Mike MiletinPFT Lab Director

Dr. Kevin Lumb

GENERAL SURGERY

Dr. Zane Jackson General Surgeon

William Osler Health System

CARDIOVASCULAR

SURGERY CLINIC

Dr. Vivek RAOChief Of Cardiac SurgeyToronto General Hospital

PLEASE INDICATE ONE

Consultation & Diagnostic Testing

Diagnostic Testing ONLY No Consultation Required.

STAT EXAMINATION

www.ihealthcenter.ca

Exercise Persantine

This requisition form can be taken to any licensed facility providing healthcare services including hospitals and IHFs.

N

427

407

50 27

7

400

IHCC -VDMC

Esso

6175 Hwy 7Units 19-22

Steeles Ave.

Finch Ave.

HolidayInnQueen St. E.

H EtobicokeGeneralHospital

7

Patients who arrive late for their appointment

or not prepared may be rebooked.

Please call 48 hours in advance if you need

to cancel or change your appointment.

Please bring your health card and a list of

your medications to your appointment.

Please note any missed appointments for

nuclear stress tests will be charged

a $100 cancellation fee.

Cardiac & Vascular Studies: No preparation is required.

Treadmill Stress Test: Wear comfortable shoes and clothing. Consult with your physician if you need to stop taking any medication prior to your test such as: Beta Blockers or Calcium Channel Blockers.

Pulmonary Function Test: No preparation is required.

Nuclear Cardiology:

· A light breakfast/lunch on day of test (piece of toast and a glass of juice) and then no food or drink for 4 hours prior to test (2hrs if diabetic).

· 24 hours prior to test - NO CAFFEINE CONSUMPTION (coffee, tea, decaffeinated coffee, decaffeinated tea, chocolate, soda, etc.)

· Consult with your physician about the temporary discontinuation of certain heart medications for 48 hours. ( eg. Beta blockers, Diltiazem, Aggrenox, Viagra, medication with caffeine, etc).

· Wear comfortable shoes and loose fitting clothes for the exercise tests.

· Bring a list of current medications and something to eat during the test.

· No lotion or powder on skin.

IHCC Integrated Healthcare CentreVaughan Diagnostic Medical Centre

6175 Hwy # 7 • Units 19 - 22 • Vaughan, ON • L4H 0P6 • Tel: 416.297.8362 • Fax: 416.840.8434

PATIENT INSTRUCTIONS

NOTE:

GETTING HERE: From Brampton:

• Take preferred route toward Highway 7/Queen Street East and take the 501/501A Züm 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 / McDonald’s / 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 / McDonald’s / 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 & Vaughan Valley Blvd. (stop #4141).

• Cross the street toward the plaza directly across the RBC Bank / McDonald’s / Swiss Chalet.

www.ihealthcenter.ca