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 limb Venous upper limb lower limb TIA / Stroke r/o Carotid Stenosis 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 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: 416-840-8434 FOR 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 Electrophysiology Toronto General Hospital IHCC Integrated Healthcare Centre Vaughan Diagnosc 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 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 DIABETES & ENDOCRINOLOGY Dr. Laura Rothman NEPHROLOGY & HYPERTENSION Dr. Christina Kim ALLERGY & IMMUNOLOGY Dr. Jaclyn Quirt RESPIROLOGY Dr. Mike Miletin PFT Lab Director Dr. Kevin Lumb GENERAL SURGERY Dr. Zane Jackson General Surgeon William Osler Health System PLEASE INDICATE ONE Consultation & Diagnostic Testing Diagnostic Testing ONLY No Consultation Required. STAT EXAMINATION www.ihealthcenter.ca