5 Junction Road, Toronto, ON M6N 1B5 T 416.766.1162 F 416.766.0463 www.riversideclinic.ca Patient Name Dob Hc#: Address Phone# Home Cell Email RAPID CARDIOLOGY ASSESSMENT CLINIC REFERRAL Date Of Referral FAX to: 416.766.0463 URGENCY: 72hr 7 days 24hr REASON FOR CONSULTATION: Chest Pain Atrial Fibrillation Syncope Dyspnea Brief history: Please attach relevant investigations / bloodwork TEST REQUESTED: STRESS TEST Treadmill stress test Exercise perfusion scan Persantine perfusion scan Echocardiogram ECG Ambulatory BP Monitor HOLTER MONITOR 24hr 48hr 7 day 14 day REFERRING PHYSICIAN: Referring Practitioner: Ohip#: Address: Phone: Fax: Cc to: Date Name: Signature Attatch a file
