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Contact Us
3080 Yonge Street Suite 4022
Toronto, Ontario M4N 3N1
647-347-6644
[email protected]
PATIENT NAME
ADDRESS
DATE OF BIRTH
GENDER
F
M
HEALTH CARD NUMBER
VERSION CODE
EMAIL ADDRESS
HOME PHONE NUMBER
CELL PHONE NUMBER
SUNNYBROOK HOSPITAL DISCHARGE PATIENT
Yes
CLINICAL EVALUATION
Consultation
Consult, if abnormal
Neuro-Vascular, Stroke, TIA Clinic
Hypertension & Diabetes
Internal Medicine & Geriatrics
Dietician Consultation
CLINICAL INFO
TESTS REQUIRED
Treadmill Stress Test
Echocardiogram
Stress Echo
12 Lead ECG
24 HR ABP Monitor (not covered by OHIP)
w/contrast
w/contrast
HOLTER MONITOR (Indicate one)
24hr
48hr
72hr
96hr
7 days
14 days
PROVIDERS
First Available
Dr. Eugene Crystal MD, FRCPC
Dr. Ilan Lashevsky MD, FRCPC
Dr. Alex Crystal MD, FRCPC
Dr. Mina Madan MD, FRCPC
Dr. Ashish Patel MD, FRCPC
Dr. Tasnim Vira MD, FRCPC
Dr. Dr. Romana Dragojevic MD, GIM & Hypertension
Dr. Houman Khosravani MD, Stroke &TIA
Dr. Christopher Lewis MD, GIM & Geriatrics
REFERRING PHYSICIAN
PHYSICIAN NAME
OHIP BILLING
PHONE NUMBER
FAX NUMBER
PHYSICIAN EMAIL
ORGANIZATION NAME
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