PocketECG
Referring Physician
Fax
CPSO Number
PATIENT INFORMATION
Name
Gender
M
F
Address
Unit
City
Province
Postal Code
DOB
Phone
InsuranceType
Public insurance
Private insurance
Cash
Health Card Number
Version Code
CC
Name
Fax
REASON FOR REFERRAL
A-Fib/Flutter R/O
Chest Pain
Dizziness
Palpitations
Shortness of Breath
Syncope
TIA/Stroke
Other
CURRENT MEDICATION(S)
ASA
ACE Inhibitor
ARB
Beta Blocker
Statin
Anti-Coagulant
Oral anticoagulant
None specified
Other
None
Does the patient have Pacemaker or Implanted Cardiac Defibrillator?
Pacemaker
Implanted Cardiac Defibrillator
Test Requested:
2 Weeks
Repeat if inconclusive (Test to be done 1 month after)
I acknowledge that I am a registered HCP.
By referring the above patient for the m-CARDS service, I acknowledge I have completed the patient education and technical set-up as outlined
here
Submit