Windsor Heart Institute
Phone: +1 (519) 977-6643
Fax: +1 (519) 915-6326
Tech Support: +1 (519) 966-7180
Register Monitor Request
Upload Holter Data
Patient Referral
Register Monitor Record
Reset
×
Patient Name:
Patient DOB:
OHIP #:
Primary Physician:
Referring Physician:
Referring Cardiologist:
Urgent / Next Available
Dr. Dhssraj Singh
Dr. Roland Mikhail
Dr. Alireza Bagherli
Dr. Nisar Huq
Dr. Rafal Sieniawski
Dr. Kushal Dighe
Dr. George Wong
Reason:
Cardiac Medications:
Monitor #:
Monitoring Start Date:
Monitor Duration:
1 day
2 day
3 day
7 day
14 day
Expected Return Date:
Notes:
Upload Holter Data
Reset
×
Filename:
Return Date:
Patient Name:
Notes:
Patient Referral
Reset
×
Patient Name:
Patient DOB:
OHIP #:
Phone #:
Diagnostic Tests:
Exercise Stress Echo with Consult
Exercise Stress Echo only (consult only if deemed necessary by MD)
2D Echocardiogram +/- contrast
Event/Loop Monitor (14 day)
EKG/Electrocardiography
24hr ABP monitor ($50)
Holter (1-3 day)
Holter (7 day)
Holter (14 day)
Indications:
Chest Pain
Dyspnea
Pre/Syncope
Arrhythmia
Stroke/TIA
Palpitations
Cardiovascular Screening
Diabetes
HTN
CAD/MI
CHF
Other
Physician Consultation Request:
Urgent / Next Available
Dr. Dhssraj Singh
Dr. Roland Mikhail
Dr. Alireza Bagherli
Dr. Nisar Huq
Dr. Rafal Sieniawski
Dr. Kushal Dighe
Dr. George Wong
Consultation:
If Diagnostic test is abnormal, please automatically arrange for cardiology consultation.
Reason:
Referring MD:
MD Billing #:
Phone #:
Fax #:
Email:
Info sheet:
Print
directions and instructional information sheet
for patient after submission
Coded with
by
Mike Busuttil