London Cardiac Institute • Lead Extraction Referral

Patient Information

In Patient Out Patient

Patient Name

Address

City

Postal Code

Home Phone

Work Phone

Cell Phone

D.O.B. (yyyy-dd-mm)

Health Card #

Version Code

Referring Physician

Name

Billing Number

Address

Telephone

Fax

Diagnosis/ Reason for Referral

Other Pertinent Information

Indication For Extraction

Infection

Pocket
Systemic
Organism

Obstruction/Access
Debulking

RQvalALPHUrgency:

Emergent (<48 hrs)
RQvalALPHUrgency (<7 hrs)
Elective

Device Details

Original Implant Date (YYYY/MM/DD)

Most Recent Implant Date (if different)(YYYY/MM/DD)

Device Type:

Dual Chamber PPM
Dual Chamber ICD
Single Chamber PPM
Single Chamber ICD
BiV PPM
BiV ICD

Pacing Mode:

Manufacturer:

Model:

RQvalALPHDependant?

Yes No

Intrinsic Rate and Rhythm:

Will the patient need a new device?

Yes No

Device Information

Lead 1

Chamber:

Model:

Manufacturer:

Age:

Comment:

Lead 2

Chamber:

Model:

Manufacturer:

Age:

Comment:

Lead 3

Chamber:

Model:

Manufacturer:

Age:

Comment:

Lead Extraction Referral

Patient Information

Referring Physician

Indication For Extraction

Device Details

Device Information

Please fax any existing rhythm strips, cardiac investigations, clinical notes, or discharge summaries along with the completed form.
Fax to: 519-645-1584

Referral Info

Lead Extraction Referral

Patient Information

Referring Physician

Indication For Extraction

Device Details

Device Information

Please fax any existing rhythm strips, cardiac investigations, clinical notes, or discharge summaries along with the completed form. Fax to: 519-645-1584

Referral Info

Please fax any existing rhythm strips, cardiac investigations, clinical notes, or discharge summaries along with the completed form.
Fax to: 519-645-1584