Online Referral Form_duplicate_1771768158

ONLINE REFERRAL

Referral Form for Healthcare Providers

Submit a referral electronically. This form is intended for healthcare providers only.

Important Notice

This form is strictly for healthcare providers submitting patient referrals. It is not intended for use by patients. If you are a patient, please speak with your doctor about a referral or contact our team for guidance.

Online Referral Form

Note: If you do not see the online form below, please use our PDF referral form.

Download Referral Form (PDF)

Patient Demographics

First Name*
Last Name*
Phone*
DOB*
HCN*
Version Code*
Address

Physician Information

Referred By*
Physician Billing No.*
Telephone*
Signature*

Cardiac Diagnostics

ECG ECG Ambulatory Blood Pressure Test (fee $80) Exercise Stress Test (GXT)

Echocardiography Transthoracic echocardiogram Stress Echocardiogram Endocardial Enhancement Agent Bubble Saline Contrast (Shunt Detection)

Holter Monitoring

7 Days 14 Days 48 Hours 72 Hours

Nuclear Myocardial Perfusion Imaging

Exercise Persantine Muga

Cardiology Consultations

Urgent First Available Consult if Abnormal Test only

With Dr.

Clinical Information*

By submitting this form, I confirm that I am a healthcare provider making this patient referral. I consent to LifeHeart Cardiology collecting and using the information provided to process the referral and communicate regarding the patient’s care. I understand that the information will be handled securely and in accordance with LifeHeart Cardiology’s Privacy Policy.

Patient Preparation

Share prep instructions with your patient before their appointment.

Office Inquiries

Phone: +1 647-255-1615

Fax: +1 647-255-1636

Email: info@lifeheartcardiology.ca

EVERY BEAT MATTERS

WE CARE, WE CAN

Home
For Patients
For Physicians
Services
Contact Us
Referral Form (PDF)

+1 647-255-1615

In Case of Emergency Please Call 911 Or Visit Your Nearest Hospital

LOCATION
SERVICES
BACK TO PAGE TOP

LOCATION
SERVICES
BACK TO PAGE TOP