E-Referral

Dr. A. Fahoum, MD

Suite 103-51 Inglewood DrSt Albert, AlbertaT8N 4E7

E-Referral

This is the electronic version of Cardio Connect’s referral form: fill out this online form and hit submit to refer a patient to our clinic. If you would prefer to download and fax a referral form, please click here.

Patient Information

Referring Physician

History

Requested Consultations
Requested Investigations
Risk Assessment
  Typical chest pain Atypical chest pain Non-specific pain Asymptomatic/ screening
Male >40yrs, Female>50yrs Rapid Access Urgent Semi-urgent Non-urgent
>30yrs Urgent Semi-urgent Non-urgent Non-urgent
<30yrs Semi-urgent Semi-urgent Non-specific Non-urgent


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