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01. Edit your western cardiology referral form online
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How to use or fill out western cardiology referral form with our platform
- Click ‘Get Form’ to open the western cardiology referral form in the editor.
- Begin by entering the REFERRAL DATE and the name of the REFERRING DOCTOR at the top of the form.
- Fill in the PATIENT NAME, PHN (Personal Health Number), DOB (Date of Birth), and GENDER. If assistance with mobility is needed, check the appropriate box.
- Provide contact information including HOME PHONE, CELL PHONE, WORK PHONE, and EMAIL. If an alternative contact is necessary, fill that section as well.
- Complete the ADDRESS section accurately to ensure proper communication.
- List any MEDICATIONS currently being taken by the patient in the designated area.
- If a TREADMILL REQUEST is applicable, ensure a 12 LEAD ECG less than 3 months old is attached and provide relevant diagnostic information.
- For a HOLTER REQUEST, indicate symptoms occurring frequently and specify any medications for evaluation.
- If requesting a CONSULTATION, include details about pre-operative surgery and requested cardiologist.
- Check off all necessary records to be forwarded for processing your referral at the bottom of the form.
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