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Your specific question or concern:
Allergies/Adverse reactions:
Suitable referrals for tele-consultation: ● For advice on how to triage, diagnose or treat your patient's potential cardiac symptoms. ● If you are uncertain about the suitability of your patient for a formal face-to-face cardiology consultation. ● For advice on the appropriate cardio-diagnostic test for your patient. ● If you would like to discuss the results of your patient’s cardiac tests or procedures. ● If you require a more urgent cardio-diagnostic test or consultation for your patient than was offered.
Current medications:
DOB: mm/dd/yyyy
Primary care MD Name:
Name:Last Name:
First Name:
PHN: Gender:
Phone:
Specialty:
Phone: Fax:
PRACID:
MD signature and Clinic Name / STAMP (Required)
Please select the day(s) of the week and time of day you are available:
Monday Thursday
Relevant past medical history:
Date of referral: mm/dd/yyyy
Patient Demographics Referring Information
Tele-Consultation Requisition
To Book an Appointment:
Fax: (403) 571-6990 Phone: (403) 571-8641
Tuesday WednesdayAM
PMFriday