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Guelph: goodhealthcps@goodclinic.ca
Markham: goodhealthmarkham@goodclinic.ca
Guelph: 226-807-6600
Markham: 289-505-9134
Home
About Us
Our Story
Meet the Team
Services
Electrocardiogram
Holter Monitoring
2d Colour Doppler Echocardiography
Exercise Stress Testing
24 Hour Ambulatory Blood Pressure Monitoring
Stress Echocardiogram
Cardiac Consultation
For Patients
ECG & Holter Monitoring Pathway
Echo & Holter Pathway
Intake + Echo + Stress Test + Consultation Pathway
Intake + Stress Echocardiogram + Consultation Pathway
Stress Test + Consultation Pathway
Intake + ECG + Consultation Pathway
Intake + Echocardiogram + Consultation Pathway
For Clinicians
Contact Us
Guelph
Markham
Online Referral
Guelph
Markham
Home
About Us
Our Story
Meet the Team
Services
Electrocardiogram
Holter Monitoring
2d Colour Doppler Echocardiography
Exercise Stress Testing
24 Hour Ambulatory Blood Pressure Monitoring
Stress Echocardiogram
Cardiac Consultation
For Patients
ECG & Holter Monitoring Pathway
Echo & Holter Pathway
Intake + Echo + Stress Test + Consultation Pathway
Intake + Stress Echocardiogram + Consultation Pathway
Stress Test + Consultation Pathway
Intake + ECG + Consultation Pathway
Intake + Echocardiogram + Consultation Pathway
For Clinicians
Contact Us
Guelph
Markham
Online Referral
Guelph
Markham
Online Referral - Markham
PATIENT INFORMATION:
First Name
Last Name
DOB
Health Card Number
VC
Phone
Email
Gender
Female
Male
REFERRING PHYSICIAN:
Clinic Name
Billing #:
Physician Name
Physician Signature
Date
Level of Urgency
Urgent
Semi-Urgent
Elective
Consultation
Consultation
Consult If Test Result Is Positive/ Abnormal
Diagnostics
Echocardiogram
Holter Monitoring
24 hr
48 hr
72 hr
14 Day
Ambulatory Blood Pressure Monitor
24 hr ($75 fee not covered by OHIP)
Stress Testing
Treadmill Stress Test with Consultation
Exercise Stress Echocardiogram with Consultation
INDICATION: Check all that apply
Chest Pain
Dyspnea
High Risk CV Profile
Atrial Fibrillation
Presyncope / Syncope
Cardiac Source of Embolism
Murmur
Palpitations
Bradycardia
Heart Failure
Cardiomyopathy
Dyslipidemia
Please provide all relevant clinical information
Send
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