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905-766-0137
info@theweightclinic.com
1547 Hurontario
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Weight loss Journey
CardioWeight
Referrals
Weight Clinic Referral
CardioWeight Clinic Referral
Contact Us
Home
Weight loss Journey
CardioWeight
Referrals
Weight Clinic Referral
CardioWeight Clinic Referral
Contact Us
Online Referral
Click Here to Fill out our Form
Download Referral Form
Patient Information
Patient's Name:
Patient's Phone:
Patient's E-mail:
Patient's Healthcard Number:
Office/ Physician Information
Referring Physician:
Office Address:
Office Phone:
Office FAX:
OHIP Billing Number:
Referral Information
Cardiac Tests Requested
Electrocardiogram (ECG)
Exercise Stress Echocardiogram Test
Holter Monitor (72 Hours)
Echocardiogram
Cardiac Consultation
History and Indication
Family history or risk factors
Chest pain
Shortness of breath
Palpitations
Dizziness
Abnormal testing like ECG
History of Cardiac Disease
CAD
CHF
Arrhythmias
Valve disease
Other cardiac diseases
Submit
