Referrals

REGISTRATION / REFERRAL FORM FOR THE CARDIAC REHABILITATION AND SECONDARY PREVENTION PROGRAM

Name: Date:

Address:

Home Phone: Work Phone:

PIN #: Birthdate:

Health Card #: Version Code:

Family Physician:

Cardiologist / Internist:

Surgeon:

Referring Physician:

Referring Physician Tel:

Heart Attack Date: Bypass Surgery Date:

Angioplasty Date: Angina Date:

Valve Replacement Date: Heart Transplant Date:

Further Information:

MAIL/ FAX COMPLETED FORM TO:
CARDIAC FITNESS INSTITUTE, SOUTHWESTERN ONT.

London Health Sciences Centre
800 Commissioners Rd. East, P.O. Box 5010
London, Ontario, Canada N6A 5W9
PH (519) 685-8372 FAX (519) 685-8337