Western cardiology referral form 2026

1. Click ‘Get Form’ to open the western cardiology referral form in the editor.
2. Begin by entering the REFERRAL DATE and the name of the REFERRING DOCTOR at the top of the form.
3. 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.
4. Provide contact information including HOME PHONE, CELL PHONE, WORK PHONE, and EMAIL. If an alternative contact is necessary, fill that section as well.
5. Complete the ADDRESS section accurately to ensure proper communication.
6. List any MEDICATIONS currently being taken by the patient in the designated area.
7. If a TREADMILL REQUEST is applicable, ensure a 12 LEAD ECG less than 3 months old is attached and provide relevant diagnostic information.
8. For a HOLTER REQUEST, indicate symptoms occurring frequently and specify any medications for evaluation.
9. If requesting a CONSULTATION, include details about pre-operative surgery and requested cardiologist.
10. Check off all necessary records to be forwarded for processing your referral at the bottom of the form.

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