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INFORMATION
Education
What is Electrophysiology?
Cardiac Mapping
Cardiac Resynchronisation Therapy (CRT)
Implantable cardioverter-defibrillators (ICDs)
Pacemakers
Pulmonary Vein Isolation
Tachycardia
What to do before you have a cardiac device implant
Follow up after a device implant
Aftercare for a device implant
For Health Professionals
Physician Forum
Videos
Useful Links
About HRM
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CONTACT
Clinic Appointments
File Submission – Doctors
Referral Form
HOME
INFORMATION
Education
What is Electrophysiology?
Cardiac Mapping
Cardiac Resynchronisation Therapy (CRT)
Implantable cardioverter-defibrillators (ICDs)
Pacemakers
Pulmonary Vein Isolation
Tachycardia
What to do before you have a cardiac device implant
Follow up after a device implant
Aftercare for a device implant
For Health Professionals
Physician Forum
Videos
Useful Links
About HRM
Locations
CONTACT
Clinic Appointments
File Submission – Doctors
Referral Form
Test
Home
Test
Referral Form
Referral
Patient Name
*
Patient Last Name
*
Date of Birth
*
Health Card #
*
CR #
*
Address
*
Phone (home)
Phone (work)
Email
Referring Practitioner
*
Referring Practitioner's Fax #
Referring Practitioner's Email
*
Patient Height (cm)
*
Patient Weight (kg)
*
Test Required:
Ambulatory BP
Bicycle stress test
CRT optimization
Dobutamine stress echo
Echocardiogram
Electrocardiogram
EP study
Exercise stress echo
Holter Monitor 48-hour
Holter Monitor 24-hour
ICD implantation
Inherited heart disease clinic and genetic testing
Pacemaker implantation
Pacemaker/ICD/ILR interrogation
Provocative drug challenge
(Long QT, CPVT, Brugada Syndrome)
Signal average ECG
Tilt table testing
Transesophageal echocardiogram
Treadmill Exercise Test (Bruce/Modified protocol)
Other
Other
Clinical History (check any appropriate boxes)
*
Unknown
Diagnosed Myocardial Infarction
Possible Ischemia Infarction
Pulmonary Disease
Hypertension
Palpitations or Syncope
Predominant Mitral Stenosis
Aortic Stenosis/Aortic or Mitral Regurgitation
Congenital Heart Disease
Pericarditis
Other
Other
Medications (check all appropriate boxes)
*
Unknown
None of the following
Digitalis
Quinidine or Procainamide or Amiodarone
Antihypertensives
Diuretics
Beta Blockers
Calcium Channel Blockers
Other
Other
Clinical Information/reason(s) for test:
EP consultation required
Yes
No
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