Tel: 519-645-0146 | Fax: 519-645-1584 | Suite 302 - 256 Pall Mall St | London, Ontario | N6A 5P6
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Referral Info
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AFIB
Pacemaker 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
Procedure Requested
New Pacemaker Implantation
Temporary Lead Insertion
Pacemaker Generator / Lead Replacement
Pacemaker or ICD Extraction / Removal
Lead Repositioning
Implantable Loop Recorder Insertion
Pacemaker System Revision
Medical Indication
Sinus Node Dysfunction
Sinus arrest (> 3 sec)
Sinus bradycardia or pauses (<3sec)
AFib/Flutter + AV block/slow V rate
Tachy-bradycardia
Sick sinus +AV block
Implantable Loop Recorder Insertion
Pacemaker System Revision
AV Block
Complete AV block-fixed
Complete AV block-intermittent
Second degree AV block
2:1 AV block
Pre-AVN ablation
Other
Unexplained syncope
Vasovagal Syncope
Hypersensitive carotid sinus
Congestive Heart Failure
Syncope with high risk profile
High risk IVCD/BBB
Hypertrophic Cardiomyopathy
Atrial fibrillation
Reason for Device Replacement/Revision
Generator energy depletion
Lead dislodgment
Lead fracture/insulation failure
Generator recall
Lead high threshold
Lead Connector issues
Pocket Infection only
Pocket / wound erosion
Infection with sepsis
Muscle / diaphragm stimulation
Hematoma
Oversensing / undersensing
Myocardial perforation
Temporary Lead?
Yes
No
Insertion Date (mm/dd/yy)
Wire Location
Medical Conditions (Check all that apply)
Diabetes mellitus
Chronic Lung Disease
Ischemic Heart Disease
Peripheral Vascular Disease
Atrial Fibrillation
Substance abuse
Psychiatric illness, dementia
Previous stroke
Malignancies
Ongoing infections
Confined to bed or wheelchair
CHF
MRSA / VRE positive
Chronic Renal Failure
On dialysis?
Drug allergies
specify:
Current Medications
Beta blockers
Insulin
ASA/Clopidogrel
Oral anticoagulation
Investigations
INR: Most recent value
Test date (mm/dd/yy)
LVEF:
<20
21-30
31-35
36-40
41-50
>51
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
Arrhythmia Service Referral
PDF
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Atrial Fibrillation Information Sheet
PDF
Catheter Ablation of Atrial Fibrillation Article
PDF
General Cardiology Referral
PDF
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Urgent Cardiology Clinic Referral
PDF
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Lead Extraction Guidelines
PDF
Lead Extraction Referral
PDF
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New ICD Referral
PDF
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Fill Out Online
Pacemaker Referral
PDF
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Fill Out Online
