Referrals

Cardiac Clinics Referral Form
This is a generic form that can be used for all St Paul's Cardiac Clinics.  Open Form
Cardiology Telehealth Referral Form
If you download this form, it is fillable for your convenience:  Referral to Cardiology Telehealth
Cardiac Rehabilitation Referral Form

Cardiac Rehabilitation Referral

This form should be completed when referring to the Healthy Heart Program.

Prevention Clinic Referral Form
Prevention Clinic Referral Form
This form should be used when referring to the Prevention Clinic
Heart Failure Clinic

Open Form

New diagnosis heart failure; suspected heart failure (with or without low ejection fraction); multidisciplinary teaching and/or optimization of therapy. **After optimization of treatment (usually 12-18 months), pts. are returned to usual GP/specialist for follow-up.**

Atrial Fibrillation Clinic Referral Form

Atrial Fibrillation Clinic Referral Form

For patients with known or suspected atrial fibrillation who are not yet on recommended treatments.

Adult Congenital Heart/Heritable Aortopathies Clinic Referral Form

ACH/HAC Referral 

Adult Congenital Heart (ACH) - Assessment and cardiac management for adults with congenital heart disease.

Heritable Aortopathies (HAC) - Comprehensive, multisystem assessment genetic disorders that effect the aorta.

Cardiac Obstetrics Clinic Referral Form

COB Referral 

Cardiac Obstetrics (COB) - Pre-pregnancy counseling and cardiac care to women with congenital and acquired heart disease at risk of developing heart complications during pregnancy. Please include number of weeks pregnant.

BC Inherited Arrhythmia Referral Form

Referral Inherited Arrhythmia

Multidisciplinary screening, evaluation and genetic counseling for patients/families affected by, or at risk for, an inherited arrhythmia, sudden unexplained cardiac arrest, sudden unexplained death, or sudden infant death syndrome

Transcatheter Valve Implantation Referral Form

Information for Referring Doctors for THV

Information for doctors who want to refer patient who have significant valvular disease and is suitable for Transcatheter Valve Implantation. 

THV Referral 

Refer if your patient has significant valvular disease and is suitable for Transcatheter Valve Implantation. This forms goes with the General Cardiology Referral Form and the Lab Requisition for General Cardiology Referral.

Pacemaker or Implantable Defibrillator Referral Form

Pacemaker Referral Form

Implantable Defibrillator Referral Form

If your patient requires assessment for or insertion of either of these devices.

 

Hypertrophic Cardiomyopathy Clinic

Hypertrophic Cardiomyopathy Clinic Referral Form

 

Contact Information

If you have questions regarding referrals or require more information, please contact:

Bonnie Kong
Assistant to the Heart Centre at St. Paul’s Hospital
Rm 444, 4th Floor, Burrard Building
Phone: 604-806-9139
Fax: 604-806-9150
Email:  bkong@providencehealth.bc.ca