DR CONG LUO
DR MARK BALLARD
DR NIKI ALIZADEH VAKILI
DR SHARAREH SAJJADI
     FAX:
205-45625 HODGINS AVE CHILLIWACK BC V2P 1P2 TEL: 604-402-2246 WWW.MYCCIM.CA DATE: Y-M-D

PATIENT INFORMATION:	REFERRING PHYSICIAN:
NAME:	NAME:
DOB: GENDER:	MSP:
ADDRESS:	ADDRESS:
PHN:	CONTACT NUMBER:
PHONE: Cel: Work:	SIGNATURE:

“Electronically signed”

URGENCY:
URGENT	SEMI URGENT	ROUTINE

REASON FOR REFERRAL:

DIAGNOSTIC TESTING REQUESTED:
EXERCISE TREADMILL TEST (includes consent)	24hr AMBULATORY BLOOD PRESSURE (includes consent)
HOLTER MONITOR           No Consult         Consult Required	EVENT MONITOR (includes consent)

PATIENT CONSENT FOR TREADMILL TEST: Testing consists of walking on a treadmill while the speed and gradient of the treadmill increase every 3 minutes. While every effort is made to minimize the risks of the procedure, there is a small risk of complications. Serious potential complications include the possibility of heart rhythm disturbance, development of heart failure, prolonged angina, heart attack or cardiac arrest and death. Emergency equipment and trained personnel are on site.             PATIENT CONSENT PROVIDED (please check box) ***Please have patient bring list of medications***

(import missing eform here )