APPOINTMENT DAY DD / MM / YYYY WEST END TIME C A R D I O L OG Y 2425 Bloor Street West, Suite 105 Toronto, ON M6S 4W4 T 416.766.1162 F 416.766.0463 CARDIAC DIAGNOSTICS & CONSULTATION Please bring health card & requisition JANE ST SUBWAY W E S PATIENT’S NAME DOB BLOOR ST W ADDRESS WEST END CARDIOLOGY 2425 Bloor St W Suite 105 PHONE# HOME WORK OHIP# CITY N JANE ST RIVERVIEW GARDENS Hours: Mon-Fri 7:30am-3:30pm $120 WILL BE CHARGED FOR LAST MINUTE CANCELLATIONS & MISSED APPOINTMENTS DD / MM / YYYY POSTAL CODE CLINICAL HISTORY LAST MENSTRUAL PERIOD I AM NOT PREGNANT LEAD PROTECTION USED PATIENT PREPARATION FOR CARDIAC NUCLEAR STRESS TEST 1. The test takes approximately 4 hours. 2. If you need to change the appointment call WEST END at 416.766.1162. 3. Wear comfortable clothing and shoes that you can exercise in. ASTHMA yes no 4. You may have a light breakfast CONSULTATION 5. Do not take anything that may contain caffeine for 12 hours. This includes coffee, tea, cola or chocolate. EXERCISE STRESS TEST (GXT) 24 HOUR HOLTER EXERCISE MYOCARDIAL PERFUSION IMAGING 48 HOUR HOLTER 6. No smoking 1 hour prior to testing PERSANTINE MYOCARDIAL PERFUSION IMAGING LOOP MONITOR VENTRICULAR FUNCTION STUDY (MUGA) ECG 7. Bring a list of your medications with you when you go for the test. (please forward most recent test results) AMBULATORY BLOOD PRESSURE MONITOR 8. Stop the following medications: REFERRING PHYSICIAN ADDRESS PHONE# FAX COPY TO SIGNATURE REFERRING # www.westendcardiology.com ECHOCARDIOGRAM
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