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3080 Yonge Street Suite 4022

Toronto, Ontario M4N 3N1

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

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

14 Loop event recorder (not covered by OHIP)

PROVIDERS

First Available Dr. Eugene Crystal MD, FRCPC Dr. Ilan Lashevsky MD, FRCPC Dr. Alex Crystal MD, FRCPC

Dr. Cam Joyner MD, FRCPC Dr. Mina Madan MD, FRCPC Dr. Ashish Patel MD, FRCPC Dr. Tasnim Vira MD, FRCPC

Dr. Dr. Romana Dragojevic MD, Internal Med. & Hypertension Dr. Houman Khosravani MD, Stroke &TIA Dr. Christopher Lewis MD, Internal Med. & Geriatrics

Dietitian-Niloufar Deilami, RD MPH

REFERRING PHYSICIAN

PHYSICIAN NAME

OHIP BILLING

PHONE NUMBER

FAX NUMBER

PHYSICIAN EMAIL

ORGANIZATION NAME

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