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Supportive Cardiology Clinic Referral


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Criteria: NYHA Class III-IV symptomatic heart failure AND
  • • Two or more heart failure-related ED visits in the past 6 months
  • • One or more heart failure-related hospital or ICU admissions in the past 6 months
  • • One or more medical comorbidities (e.g., CKD, COPD, cancer, etc.)

NYHA Class: *
Palliative Care Referral: *


Patient Information

Last Name: *
First Name: *
Sex: *
Referral Date: *
Select a date from the calendar.
Address:
Postal Code: -
DOB: Day: Month: Year:
OHIP#: - - -
Primary Tel (Home): * ( )- -



Referring Physician/Healthcare Provider Information

First Name: *
Last Name: *
Primary Telephone: * ( )- -
Fax: ( )- -
Email:
MD Billing#: *
Address:
Consent: *
Please add any additional information or your clinical question here. Thank you:


Please fax (416-756-6702) to our clinic the following:

Discharge Summary, Diagnostics tests, ECG, Consult note and reports, Medication List, x-rays, Cardio Tests, Echo, Recent lab investigations including CBC, Electrolytes, AST, ALP, Cr Albumin and Lipid Profile