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O.H.I.P requires you to bring your current updated health card and
a requisition signed by the ordering physician

Fax: 416-494-8611

TDS CARDIOLOGY

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Requisition Forms

Click below to download our requisition form OR complete our online requisition

Patient Name

Sex *

Male

Female

Address

Phone

Birthday

Health Card #:

Version Code:

TEST & IMAGING OPTIONS

1. Stress Myocardial Perfusion (S-M81)

2. Persantine Myocardial Perfusion (P-M8I)

3. Rest Ventricular Function (Rest Muga)

4. Graded Exercise Stress Testing

5. Complete Echo/Doppler Study

6. Stress Echocardiogram

7. Contrast Echo/Doppler Study

8. Contrast Stress Echocardiogram

9. 24 Hour Holter Scan

10. 48 Hour Holter Scan

11. 72 Hour Holter Scan

12. Ambulatory BP Monitor ($70.00)

Cardiology Consultation Request

Referring Physician

Physician Billing Number:

Thank you for your requisition. We will be in touch in 1-2 business days.

Fax: 416-494-8611

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