E-Referral

Fax: 403-879-7899

#250-8500 Blackfoot Trail SE Calgary, AB T2J 7E1
Tel: 403-879-7911
www.chestpainclinic.ca

 

Fax: 403-879-7899

 

#250-8500 Blackfoot Trail SE
Calgary, AB T2J 7E1
Tel: 403-879-7911
www.chestpainclinic.ca

 

    Patient Information

    MaleFemale

    Referring Physician


    Urgency
    24 hrs48 hrs72 hrs1 Week

    Chest Pain Rating
    Angina

    TypicalAtypical
    12345678910

    Medical History





    Check All That Apply
    Diabetes
    Hypertension
    Hyperlipidemia
    Known CAD
    Smoker
    Past
    Current
    Strong Family History of Heart Disease
    Abnormal ECG
    Abnormal Stress Test
    Abnormal Coronary CT
    History of Myocardial Infarction
    History of Heart Failure
    Peripheral Artery Disease
    History of COPD
    Atrial Fibrillation
    Palpitation
    History of CABG
    History of Valvular Surgery
    Shortness of Breath
    Obstructive Sleep Apnea
    Additional Information / Report Attached
    ECG
    Lab
    Stress Test
    Echo
    MPI
    X-Ray
    CT
    MRI
    Holter
    24ABP



    CONFIDENTIALITY STATEMENT: Information contained in this communication may be confidential and is intended only for the use of the recipient(s). If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication or any of its content is strictly prohibited. If you receive this communication or any of its contents in error please return it to the sender and contact Advanced Cardiology 403.235.4109