Tel: 519-645-0146 | Fax: 519-645-1584 | Suite 302 - 256 Pall Mall St | London, Ontario | N6A 5P6
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ICD CRT Referral

Patient Information

Referring Physician

Please Select The Appropriate Boxes



LVEF ≤ 30% - determined while patient was stable and after 3 months on Optimal Rx





NYHA Class Determined:








ms



Please Select the fields that are applicable


Atrial Fibrillation
Oral anticoagulants:


Prosthetic Heart Valve or Structural Valvular Disease

Diabetes Mellitus?
Diabetes Control:


Symptomatic Bradycardia
Hypertension
Cognitive Impairment

HX of CVA/TIA?
Disability Level:


Chronic obstructive lung disease?

History of Drug/ETOH, major psych illness?
Current Drug/ETOH, major psych illness:


History of Cancer?


Patient on dialysis or chronic renal failure?
Most recent serum creatinine:



IMPORTANT PLEASE ATTACH:







Please fax any existing recent consults, MUGA/ECHO results, ECG results, or Cardiac Catheterization. Fax to: 519-663-3782



Referral Info

Arrhythmia Service Referral

PDF | Fill Out Online

Referral Form
Atrial Fibrillation Information Sheet

PDF

Referral Form
Catheter Ablation of Atrial Fibrillation Article

PDF

Referral Form
General Cardiology Referral

PDF | Fill Out Online

Referral Form
Urgent Cardiology Clinic Referral

PDF | Fill Out Online

Referral Form
Lead Extraction Guidelines

PDF

Referral Form
Lead Extraction Referral

PDF | Fill Out Online

Referral Form
New ICD Referral

PDF | Fill Out Online

Referral Form
Pacemaker Referral

PDF | Fill Out Online

Referral Form
 
 
 
 
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