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Kidney Bladder Prostate Other Chronic Kidney Disease Hypertension Kidney Stones Hematuria Proteinuria Gastroscopy Colonoscopy Gallbladder Hernia Breast Ano-Rectal Other Aorta Arterial Arms Legs Venous Arms (DVT) Legs (DVT) Other 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 Thyroid Other VASCULAR PULMONARY DIABETES & ENDOCRINOLOGY Carotid & Vertebral Vascular Screen Please fax referrals, along with all relevant notes, labs, and test results to the central booking line: 416-840-8434 FOR STAT OR URGENT REFERRALS, PLEASE CALL 416-297-8362, THEN PRESS OPTION 4 Allergic rhinitis Asthma Drug allergy Stinging insect allergy Immunodeficiency Urticaria and angioedema Food allergy Eczema Other ALLERGY & IMMUNOLOGY UROLOGY INFECTIOUS DISEASE TB HIV Other Reason for Referral Diagnostic Tests Reason for Referral Diagnostic Tests GENERAL SURGERY & ENDOSCOPY DIABETES EDUCATION CLINIC Diabetes Type: Duration: Co-Morbidities: Dr. Edyta Dudzic HEART RHYTHM CLINIC Dr. K . Nanthakumar Chief of Electrophysiology Toronto General Hospital OHIP Provider ID #: Physician Signature: Copy to: Physician Name: Fax: 6175 Hwy # 7 Units 19 - 22 Vaughan, ON L4H 0P6 Tel: 416.297.8362 Fax: 416.840.8434 Peripheral Vascular Disease Aortic Aneurysm Carotid Disease Varicose Veins Referring Physician (Print): NEPHROLOGY & HYPERTENSION Other Patient Name: DOB: F Health card: Tel: M Please affix label here. MULTIDISCIPLINARY TEAM Dr. Ram Aggarwal Medical Director CARDIOLOGY GROUP (ECPG) Dr. Lee Daba Director of Cardiology Dr. Ram Aggarwal Dr. Vini Kunanithy INTERVENTIONAL CARDIOLOGY Dr. Dominic Raco Corporate Chief of Cardiology William Osler Health System CARDIOVASCULAR SURGERY CLINIC Dr. Vivek Rao Chief of Cardiac Surgery Toronto General Hospital Dr. Maral Ouzounian Dr. Mitesh Badiwala NUCLEAR CARDIOLOGY Dr. Lee Daba Dr. Mark Iwanochko VASCULAR SURGERY Dr. Al Lossing Southlake Health Centre Dr. Leonard Tse Dr. Varun Kapila DIABETES & ENDOCRINOLOGY Dr. Laura Rothman NEPHROLOGY & HYPERTENSION Dr. Christina Kim ALLERGY & IMMUNOLOGY Dr. Jaclyn Quirt UROLOGY Dr. Rajiv Gupta INFECTIOUS DISEASE Dr. Mahin Baqi RESPIROLOGY Dr. Mike Miletin PFT Lab Director Dr. Kevin Lumb GENERAL SURGERY Dr. Zane Jackson CARDIOLOGY Clinical History: Reason for Referral Diagnostic Tests Consultation & Diagnostic Testing Diagnostic Testing ONLY *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. Arrhythmia, Palpitations Dizziness / Syncope Murmur / Valve Disease CAD / MI / PCI / CABG Other Abnormal ECG Chest pain CHF Dyspnea / SOB Exercise Persantine Holter Monitoring 2-D Echocardiogram Stress test (GXT) Stress - Echo 48 hr 72 hr 14 day holter/event 24 hr Ambulatory BP monitoring (Note $50 charge to patient) MUGA Scan for Ventricular Function - Ejection Fraction Myocardial Perfusion Imaging STAT Examination CONSULTATION REFERRAL FORM

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Kidney Bladder Prostate Other

Chronic Kidney Disease Hypertension Kidney Stones Hematuria Proteinuria

Gastroscopy Colonoscopy Gallbladder Hernia Breast Ano-Rectal Other

AortaArterial Arms Legs Venous Arms (DVT) Legs (DVT)Other

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 Thyroid Other

VASCULAR

PULMONARY

DIABETES & ENDOCRINOLOGY

Carotid & Vertebral Vascular Screen

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

Allergic rhinitis Asthma Drug allergy Stinging insect allergy Immunodeficiency

Urticaria and angioedema Food allergy Eczema Other

ALLERGY & IMMUNOLOGY

UROLOGY

INFECTIOUS DISEASE

TB HIV Other

Reason for Referral Diagnostic Tests

Reason for Referral Diagnostic Tests

GENERAL SURGERY & ENDOSCOPY

DIABETES EDUCATION CLINIC

Diabetes Type: Duration: Co-Morbidities:

Dr. Edyta Dudzic

HEART RHYTHM CLINIC

Dr. K . Nanthakumar Chief of ElectrophysiologyToronto General Hospital

OHIP Provider ID #:

Physician Signature:

Copy to:

Physician Name:

Fax:

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

Peripheral Vascular DiseaseAortic Aneurysm

Carotid DiseaseVaricose Veins

Referring Physician (Print):

NEPHROLOGY & HYPERTENSION

Other

Patient Name:

DOB: F

Health card:

Tel:

M

Please affix label here.

MULTIDISCIPLINARY TEAM

Dr. Ram AggarwalMedical Director

CARDIOLOGY GROUP (ECPG)

Dr. Lee DabaDirector of Cardiology

Dr. Ram AggarwalDr. 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

Dr. Leonard TseDr. Varun Kapila

DIABETES & ENDOCRINOLOGYDr. Laura Rothman

NEPHROLOGY & HYPERTENSIONDr. Christina Kim

ALLERGY & IMMUNOLOGYDr. Jaclyn Quirt

UROLOGYDr. Rajiv Gupta

INFECTIOUS DISEASEDr. Mahin Baqi

RESPIROLOGY

Dr. Mike MiletinPFT Lab DirectorDr. Kevin Lumb

GENERAL SURGERYDr. Zane Jackson

CARDIOLOGY

Clinical History:

Reason for Referral Diagnostic Tests

Consultation & Diagnostic Testing Diagnostic Testing ONLY

*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.

Arrhythmia, Palpitations

Dizziness / Syncope

Murmur / Valve Disease

CAD / MI / PCI / CABG

Other

Abnormal ECG

Chest pain

CHF

Dyspnea / SOB

Exercise Persantine

Holter Monitoring

2-D Echocardiogram Stress test (GXT) Stress - Echo

48 hr 72 hr 14 day holter/event24 hr Ambulatory BP monitoring (Note $50 charge to patient)

MUGA Scan for Ventricular Function - Ejection Fraction

Myocardial Perfusion Imaging

STAT Examination

CONSULTATION REFERRAL FORM

Diagnostic Testing ONLY STAT Examination

N

427

407

50 27

7

400

IHCC -VDMC

Esso

Steeles Ave.

Finch Ave.

HolidayInnQueen St. E.

H EtobicokeGeneralHospital

7

6175 Hwy 7Units 19 -22

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 and Vaughan Valley Blvd. (stop #4141).

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

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

Patient Preparation Instructions

Please bring a list of current medications to your appointment

ULTRASOUND

Vascular Screen / Aorta UltrasoundWe require that you have an empty stomachNo eating or drinking 8 hours prior to the appointment

All other Vascular Ultrasound & 2-D Echocardiogram (Non-Stress):No restrictions on food or drinkNo preparation required

Stress EchocardiogramWear comfortable shoes and clothing(Please do not wear a one-piece garment)

Exercise Treadmill Stress Test (GXT)Wear comfortable shoes and clothing• Women should wear a bra preferably with no underwire• Do not wear a one-piece garment

Nuclear CardiologyThis test takes approximately 2 - 4 hours and you will receive anintravenous injection• Wear comfortable shoes and clothing for the exercise stress test• Women should wear a bra preferably with no underwire• Do not wear a one-piece garment• NO CAFFEINE 24 hours prior to the test

• No Tylenol 2’s or 3’s for at least 48 hours prior to the test• Do not smoke for 2 hours before the test• Have only a light breakfast on the day of the test (toast and juice) and then no food or drink 4 hours prior to the test (2 hours if you're a diabetic) Water is allowed • Bring something to eat during the test• Bring a list of current medications• Do not apply cream, lotion, or powder to your skin

Myocardial Perfusion Imaging (Exercise)Discontinue beta blockers 48 hours prior to the exam with your doctor’s approvalInsulin-dependent diabetic patients should take their insulin with a light meal 3 hours prior to the exam

Myocardial Perfusion Imaging (Persantine)Discontinue theophylline derivatives 48 hours prior to the exam with your doctor’s approval Insulin-dependent diabetic patients should take their insulin with a light meal 3 hours prior to the exam

Pulmonary Function TestPlease avoid smoking on the day of your testDo not use bronchodilators on the day of your testPlease bring a list of current medications

Please remember to bring your Health Card and this requisition signed by a registered physician

If you would like to cancel / change your appointment, please notify our office at least 24 hours prior to your scheduled time

• Refrain from any coffee, tea, soft drinks, chocolate beverages, energy drinks (even the decaffeinated varieties)

Consult with your physician if it is ok to discontinue Beta-Blockers(Bisoprolol, Metoprolol, etc.) 48 hours prior to your exam

Consult with your physician if it is ok to discontinue Calcium Channel Blockers (Diltiazem, Verapamil, etc.) 24 hours prior to your exam