NAME
D.O.B.
HEALTH CARD #
TELEPHONE #
DATE
TIME
APPOINTMENT
TOLL FREE TEL: 1-888-882-1731 FAX: 1-888-882-1719
960 Lawrence Ave. West
Suite 205
Toronto, ON M6A 3B5
Tel: 416 256-7100
Fax: 416 256-7147
YORKDALE CARDIOLOGY
372 Hollandview Trail
Suite 304
Aurora, ON L4G 0A5
Tel: 905 713-1300
Fax: 905 713-1302
AURORA CARDIOLOGY
Georgina Health Centre
716 The Queensway South
Keswick, ON L4P 4C9
Tel: 1-888-882-1731
Fax: 1-888-882-1719
GEORGINA CARDIOLOGY
Cardiology
Associates
REFERRAL FORM
DATE MD
URGENT
INFORM REFERRING PHYSICIAN OF SCHEDULED TIME
ECHOCARDIOGRAM
STRESS ECHO
STRESS TEST
HOLTER MONITOR
LOOP/EVENT RECORDER
14 DAYS (not covered by OHIP)
AMBULATORY BP MONITOR
ECG
48 HR 72 HR 7 DAYS 14 DAYS24 HR
48 HR (not covered by OHIP) 24 HR
CARDIOLOGY CONSULTATION
...
ADD CONTRAST TO ECHO OR STRESS ECHO
BOOK A CONSULTATION IF TEST RESULTS ARE ABNORMAL
Please forward for Consults: Previous ECG, blood work, and prior cardiac investigation results
ABNORMAL ECG
ABNORMAL GXT
ARRHYTHMIA / A. FIB.
CHEST PAIN / ACS
CARDIAC MASSES
CARDIAC RISK FACTORS
CARDIOMYOPATHY
DIZZINESS
EMBOLIC EVENTS
ENDOCARDITIS
HEART MURMUR
HIGH BP / HTN
HISTORY / SUSPECTED MVP
HISTORY OF CAD
HISTORY OF CHF
HISTORY OF MI / STROKE
PALPITATIONS
PEDAL EDEMA
PERICARDIAL DISEASE
PRE-CARDIOVERSION
PROSTHETIC VALVE/S
PULMONARY HTN/DISEASE
SHORTNESS OF BREATH
SYNCOPE
THORACIC AO DISEASE
VALVULAR DISEASE
PATIENT INFORMATION
SERVICES
INDICATIONS/CLINICAL INFORMATION
www.avdiagnostics.ca
All our offices are wheelchair accessible
716 The Queensway South
The Queensway
Ravenshoe Rd
Mc Millan Dr
Crestview Blvd
Beverley Dr
Echocardiogram is an ultrasound of the heart. The test shows live moving images of your heart.
A technologist uses a gel to slide a microphone-like device over the chest area. No radiation is involved
in the heart ultrasound.
There is no special preparation required for an echocardiogram
You should plan on being at the lab for about 45-60 minutes
You will be exercising by walking on a treadmill. Your vitals and ECG will be monitored continuously.
For Stress Echo studies, ultrasound images will be taken before and after exercise.
Please bring a list of all your current medications. Do not take the following medications
in the 24 hours prior to your test: Metoprolol, Diltiazem, Acebutolol, Atenolol and Bisoprolol,
unless advised otherwise by your referring doctor.
On the day of the test, have a light meal before the test
clothes (shorts and T-shirt)
You should plan on being at the lab for about 30-60 minutes (exercise part of the test usually
takes only 5-15 minutes).
Also known as an ambulatory ECG monitor, a Holter monitor records your heart rhythm for an entire
recording period. Wires from electrodes on your chest connect to a battery-operated recording device worn on
a belt or shoulder strap. While wearing the monitor, you may keep a diary of your activities and
symptoms, which will later be correlated with the ECG recordings. Please carry out all your activities as
usual except for bathing. Hook up takes 15-25 minutes.
A loop monitor is a patient-activated recording device which is used to record your ECG during symptoms
recorded data will be analyzed and correlated with documented symptoms. Hook up takes 15-25 minutes.
Ambulatory blood pressure monitor will measure and record your BP readings for 24 or 48 hours. The
recorder will take measurements of your blood pressure every twenty minutes during the day and every hour
during sleep. Hook up takes 15-25 minutes. Please carry out all your activities as usual except for bathing.
No preparation is required. However, avoid exercising just before the test.
You should plan on being at the lab for about 10-20 minutes.
Please bring or ask your referring physician to forward any relevant cardiac records or investigation reports.
Please bring all your current medications at all visits (including follow up appointments).
Bayview Ave.
Wellington St.
Hollandview Trail
St Johns Sideroad
372 Hollandview Trail, Suite 304
N
Apex Rd.
Lawrence Ave. West
Duerin St.
N
Joe Dales Dr
960 Lawrence Ave. West, Suite 205
Good
Shepherd Ct.
Duaw Rd.
YORKDALE CARDIOLOGY AURORA CARDIOLOGY GEORGINA CARDIOLOGY
ECG
ECHOCARDIOGRAM
STRESS TEST AND STRESS ECHO
HOLTER MONITOR
LOOP RECORDER / CARDIAC EVENT RECORDER
(not covered by OHIP)
AMBULATORY BLOOD PRESSURE MONITOR (not covered by OHIP)
CONSULTATION APPOINTMENTS