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Western cardiology referral form

Western cardiology referral form 2025

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The document is a referral form from Western Cardiology Associates, detailing the necessary information and requirements for patient referrals, including personal details, medical history, and specific requests for tests such as treadmill and Holter monitors. It outlines the documentation needed for processing referrals and emphasizes the importance of attaching recent ECG results.

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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 being evaluated.
If a CONSULTATION REQUEST is needed, include details about pre-operative surgery and requested cardiologist.
Check off all required records to be forwarded for processing your referral before submitting.

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What are the indications for cardiology referral?

Please include in your referral: Cardiac arrhythmias. o Haemodynamic instability o Shortness of breath o Chest pain o Heart failure o Current syncope or pre-syncope o Sustained heart rate 150 beats per minute o Known Wolff-Parkinson-White syndrome.

What is a cardiology indication?

You have shortness of breath, palpitations or dizziness. A cardiologist can determine if a heart condition is the cause. These symptoms may be a sign of abnormal heart rhythm or coronary artery disease.

Why would I be referred to cardiology?

Your primary care provider may refer you to a cardiologist if you have a problem with your heart or blood vessels that needs extra care. Your cardiologist may keep working with you for a long time as they monitor your condition. You may need to see a cardiologist if you have: Pain in your chest.

How can I get a referral to a cardiologist?

When to see a cardiologist? Your PCP may refer you to a cardiologist if you have heart disease, want to manage the risks of heart disease, or have warning signs of a heart problem. Some warning signs include dizziness, fatigue, shortness of breath, chest pain, heart rate changes, and more.

How to get a cardiology referral?

Primary Care Physician Referral: In many healthcare systems, the usual process is to first visit your primary care physician (PCP) or general practitioner. If your PCP identifies or suspects a cardiac issue, they may then provide you with a referral to a cardiologist for further evaluation and treatment.

When should you be referred to a cardiologist?

In addition to chest pain with activity (also called angina), you may experience: Chest tightness, pressure, or discomfort. Pain that starts near your chest and reaches your shoulder, arm, jaw, neck or back. Shortness of breath. Heart palpitations (less common)

Western cardiology referral form 2025

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