OCC Requisition Form - Ottawa Cardiovascular Centre

OCC Requisition Form - Ottawa Cardiovascular Centre

Cardiovascular Excellence since 1987
Name:
Referring Physician:
Address:
Copy to:
OHIP Number:
Telephone:
DOB (d/m/y):
OHIP Billing Number:
Consultation
Urgency
m Cardiologist m Pediatric Cardiologist
m Specific MD:
m CV-Focused Internist
m Endocrinologist
OCC Cardiologists
m Weeks m Elective
OCC Cardiovascular Focused Internists
m Dr. Chamoun Chamoun
m Dr. John Dawdy
m Dr. John Fulop
m Dr. Nassoh Hafez
m Dr. Samir Hazra
m Dr. Rob Maranda
m Dr. Joel Niznick
m Dr. Brendan Quinn
m Dr. Binny Kuriakose
m Dr. Alain Baldo
m Dr. Dora Liu
m Dr. Dan Boivin
(Endocrinology)
m Dr. Sanjeev Chander
m Dr. Carolyn Tharson
m Dr. Jodi Heshka
m Dr. Nina Ghosh
(CardioOncology)
m Dr. Angela Seshadri
(Pediatric Cardiology)
Non-Invasive Investigation
Indication
m Exercise Stress Test (Treadmill)
m Echo/Doppler
m Exercise Stress Echo (Treadmill)
m Holter Monitor
m Ambulatory BP Monitor (not covered by OHIP)
Cardiac Loop Recorder m 2 week m 4 week
m Chest pain
m Ischaemia Assessment
m Dyspnea
m Palpitation
m Atrial Fibrillation
m Syncope
m Murmur
m F/U Valvular Heart Disease
m F/U Prosthetic Valve
m Heart Failure
m LV Function
m TIA/Stroke Workup
m Follow-up Pericardial Disease
Nuclear Cardiology
m Treadmill Exercise Myocardial Perfusion Imaging (MPI)
m Persantine Myocardial Perfusion Imaging (MPI)
(Persantine testing contraindicated in asthmatics)
m Nuclear Wall Motion Study (MUGA/RNA)
Medical History
Details:
m Days
Suggested Appropriate Investigation
As per Ischaemia algorithm
As per Ischaemia algorithm
m Echocardiogram / Ischaemia algorithm
m Echocardiogram m Holter monitor or m Loop
m Echocardiogram m Holter monitor or m Loop
m Echocardiogram m Holter monitor or m Loop
m Echocardiogram
m Echocardiogram
m Echocardiogram
m Echocardiogram m Nuclear Wall Motion Study
m Echocardiogram m Nuclear Wall Motion Study
m Echocardiogram m Holter monitor or m Loop
m Echocardiogram
* Please note that the Ottawa Cardiovascular Centre will arrange appropriate diagnostic testing prior
to consultation on your behalf as required unless it has been done recently. *
m Infarct: m Medications:
m Cardiac Cath:
Risk Factors m Hypertension
m Smoking
m Hyperlipidemia: TC:
ACR:
hsCRP:
Physician’s Signature:
m DM: Glucose:
TG:
HDL:
TSH:
m PTCA: A1C:
LDL:
m CABG:
m Family History CAD
TC/HDL:
Date:
Ottawa Cardiovascular Centre
502-1355 Bank Street, Ottawa, Canada K1H 8K7
Tel: 613-738-1584 Fax: 613-738-9097
www.ottawacvcentre.com & www.cvtoolbox.com
Cardiovascular Excellence since 1987
Name / Nom :
DOB (d/m/y) / Date de naissance (j/m/a) :
Address / Nom :
Referring Physician / Nom :
Copy to / Copie à :
OHIP Number:
Telephone / Télephone :
OHIP Billing :
Cardiology / Consultation cardiologie
m Specific MD / Médecin spécifique :
m Cardiologist / Cardiovascular-Focused Internist / Cardiologue
m Pediatric Cardiologist / Cardiologue pédiatrique
Priority / Priorité m Routine m Urgent
Stress Tests / Examens diagnostiques
m Exercise Stress Test / Épreuve d’effort cardiaque
m Myocardial Perfusion with Treadmill / Perfusion myocardique au tapis roulant
m Myocardial Perfusion with persantine (no exercise) / Perfusion myocardique au persantin (sans execise)
Cardiac Structure & Function Assessment / Structure Cardiaque et évaluation fonctionnelle
m Echocardiogram / Échocardiogramme
m MUGA scan (Cardiac Gated blood pool study) / Ventriculographie isotopique
Monitoring / surveillance
m Holter Monitor / Moniteur Holter 48hrs
m Loop Montor 2 weeks / Moniteur loop 2 semaines
Clinical Information / Renseignements cliniques
Medical History / Antécédents médicaux :
Medications / Médicaments :
Risk Factors / Facteurs de risque :
Physician’s Signature:
Date:
Ottawa Cardiovascular Centre Orleans
5929 Jeanne D’Arc South, Ottawa, ON K1C 6V8
Tel: 613-749-5421 Fax: 613-830-8211
www.ottawacvcentre.com & www.cvtoolbox.com