Tel: 519-645-0146 | Fax: 519-645-1584 | Suite 302 - 256 Pall Mall St | London, Ontario | N6A 5P6
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Instructions for Referring Physicians

We offer three easy methods for referring physicians to make patient consultation referrals or to order a cardiac test for their patient:

1. On-line patient referral:

a. Fill in the required patient and referring MD information.  

b. Make sure you check the box indicating whether it is a referral for cardiac consultation or for diagnostic cardiac tests.

c. Click the "Send Message" button at the bottom. Once sent, FAX ALL RELEVANT MEDICAL HISTORY AND TEST RESULTS FOR THAT PATIENT    TO THE LCI FAX NUMBER (519-645-1584)

2. Fax referral:

a. Print a referral or test requisition form (PDF format) by clicking the appropriate button to the right  

b. Attach all relevant patient medical information and fax the referral package to 519-645-1584

3. Mail referral: Send the patient referral or cardiac test request the old-fashioned way (surface mail).

LCI will contact your office (via the same method you sent the referral) the next business day to acknowledge receipt of the referral request and book the patient appointment as soon as possible.

It is that simple and easy.

 
 
 

General Cardiology Referral

Patient Information

Referring Physician















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 | 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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