HEART FAILURE CLINIC

Document Sample
HEART FAILURE CLINIC Powered By Docstoc
					                     QUEENSWAY CARLETON HOSPITAL
                         HEART FAILURE CLINIC:
                             Referral Form

    Date of
    referral:
    Referring MD:
    (please print)
    Office Tel #

    Patient Name:
    (please print)
    OHIP #

    Phone #1

    Phone #2


   Reason(s) Referred to Heart Failure Clinic:

         □ Repeat visit(s) to ER with Heart Failure symptoms
         □ New diagnosis of Heart Failure
         □Other(explain)___________________________________________
   _____________________________________________________________
   _____________________________________________________________
   _____________________________________________________________

   Investigations:

      CXR:                Echo:                  ECG:
   □ Completed            □ Completed            □Completed
   □ Ordered              □ Ordered              □Ordered

*attach copy of tests *

          *For referral to DR. MILLER*- FAX TO: (613) 721 2582

         *For referral to DR. MCKIBBIN*-FAX TO: (613) 721 4763

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:17
posted:5/3/2012
language:English
pages:1