All referral forms on this website are also available as eForms for OSCAR, Avaros, Indivicare, and ACCURO EMRs. You can download some of the premade forms here from WorldEMR or fill the contact form below for any other eForms that are not listed for your EMR.
Table of Contents
Clinics
| Clinic | Services | Location | Form | Contact | Information |
|---|---|---|---|---|---|
| Cardio Health | 1. Cardiology Consult 2. Internal Medicine 3. Echocardiogram 4. Holter 72 hours 5. ECG 6. Stress ECHO/consult 7. AMBP monitoring 8. Nuclear cardiology | 990 Gainsborough Rd London, ON N6H 5L4 1807 Wonderland Rd N London, ON N6G 5C2 | Cardio Health London Referral | Phone: 877-718-2196 Fax: 877-718-0283 | Fax Referral Website: https://cardiohealth.ca/ |
| London Cardiac Institute | 1. Urgent Cardiology 2. Arrhythmia 3. Cardiac Testing | 1055 Fanshawe Road West London, ON N6A 5P6 | LCI Referral ArrhythmiaGeneric FormOnline referral | Phone: 519-645-0146 Fax: 519-645-1584 | https://londoncardiac.ca/ |
| LHSC Cardiac Testing | Non-Invasive Testing | LHSC University Or Victoria | LHSC Cardiac Referral | FAX UH: 519-663-3806 Fax VH: 519-685-8084 | Fax referral |
| SJHC Cardiac Testing | Non-Invasive Testing | St. Joseph’s Hospital Room B3-030 (Central Registration Desk) 268 Grosvenor Street London, Ontario N6A 4V2 | SJHC Cardiac Referral | Phone: 519 646-6019 Fax: 519 646-6292 | Fax referral |
| Anti-coagulation Clinic (UH) | Anticoagulation for cardioembolic indications | LHSC University Hospital | Anticoag Referral Form | Phone: 519-663-3605 Fax: 519-663-3614 | Fax referral |
| Coronary CATH Referral (CCN) | Coronary Catheterization | LHSC University Hospital | CCN Referral Form | Fax: 519-663-3069 | Fax Referral |
| Pediatric Cardiology Clinic | Pediatric Cardiology | LHSC Victoria Hospital | Generic Form | Phone: 519-685-8237 Fax: 519-685-8584 | Fax Referral Specific Cardiologists Below |
| Cardiac Rehab | Cardiac Rebab | SJHC B3-689 *many Locations in LHIN* | Cardiac Rehab | Phone: 519-667-6704 Fax: 519-667-6532 | Fax Referral |
| Woodstock Hospital Cardiac Investigations | Cardiac Testing and Consultation | Woodstock Hospital | Woodstock Cardiac Investigation Requisition | Fax: 519-421-4238 | Fax Referral |
| MyHealth Arva | Cardiac Testing and Consultation | MyHealth Centre Arva 21589 Richmond St Arva, ON N0M 1C0 | MyHealth Arva Referral | Phone:519-672-0070 Fax: 519-850-0144 | Fax Referral |
| MedPoint Cardiac Testing | Cardiac Testing and Consultation | Medpoint Health Care Centre – Citi Plaza 355 Wellington St, Suite 233 London, ON N6A 3N7 | Medpoint Referral | Fax: 519-663-3069 | Fax Referral |
| Cardio Study | Cardiac Testing and Consultation | Cardio Study of London Suite 202-240 Wharncliffe Rd N London, ON N6H 4P2 | Cardio Study Referral | Phone: 226-785-0460 Fax: 226-785-0466 | Fax Referral |
| KMH Woodstock Cardiac Testing | Cardiac Testing and Consultation | KMH Cardiac Testing 437 Norwich Ave Woodstock, ON N4S 3W5 | KMH Cardiology Referral | Phone: 1-877-564-5227 Fax: 1-877-564-3297 | Fax Referral |
| Medi-Share Strathroy | Holter | Strathroy Middlesex General Hospital | SMGH Holter Requisition | Phone: 519-245-5295 ext. 5531 Fax: 519-246-5919 | Fax Referral |
Physicians
| Physicians | Subspecialty / Interest | Location | Form | Contact | Information |
|---|---|---|---|---|---|
| Dr. Thain, Andrew | 1. Hypertrophic Cardiomyopathy | LHSC | Generic Form | Phone: 519-663-3010 Fax: 519-663-3578 | Fax consult |
| Dr. McCarty, David | 1. General Cardiology 2. Hypertrophic Cardiomyopathy | LHSC | Generic Form | Phone: 519-663-3227 Fax: 519-663-3578 | Fax Consult |
| Dr. Pickering, Geoffrey | 1. General Cardiology | LHSC | Generic Form | Phone: 519-663-3973 Fax: 519-434-3278 | Fax Consult |
| Dr. Shoemaker, Gerald | 1. General Cardiology | LHSC | Generic Form | Phone: 519-663-3485 Fax: 519-663-3484 | Fax Consult |
| Dr. Wisenberg, Gerald | 1. General Cardiology | LHSC | Generic Form | Phone: 519-663-3083 Fax: 519-663-3084 | Fax Consult |
| Dr. Tang, Anthony | 1. General Cardiology | LHSC | Generic Form | Phone: 519-663-3746 Fax: 519-663-3782 | Fax Consult |
| Dr. Weingert, Michael | 1. General Cardiology | 190 Wortley Rd, London ON, N6C 4Y7 230 First Ave, St. Thomas ON, N5R 4P5 | Generic Form | Phone: 519-663-7800 Fax: 519-663-0933 (St.Thomas) Fax: 519-642-1158 (London) | Fax Consult |
| Dr. Brown, Robert | 1. General Cardiology | MedPoint Healthcare 1295 Riverbend Road, London Ontario N6K 0G2 | Medpoint Referral | Phone: 519-432-1919 Fax: 519-432-9529 | Fax Consult |
| Dr. Calvin, James | 1. General Cardiology | LHSC – VH | Generic Form | Phone: 519-663-3892 Fax: 519-663-8619 | Fax Consult |
| Dr. Suskin, Neville | 1. General Cardiology 2. Cardiac Rehabilitation | SJHC | Generic Form | Phone: 519-646-3583 Fax: 519-646-6139 | Fax Consult |
| Dr. Bergin, Lynn | 1.Adult Congenital HD | LHSC | Generic Form | Phone: 519-663-3486 Fax: 519-663-3487 | Fax Consult |
| Dr. Siu, Sam | 1. Adult Congenital HD 2.Pregnancy & HD | LHSC | Generic Form | Phone: 519-434-3278 Fax: 519-434-3278 | Fax Consult |
| Dr. Bagur, Rodrigo | 1. Interventional (PCI | TAVI) | LHSC | Generic Form | Phone: 519-663-3997 Fax: 519-434-3278 | Fax Consult |
| Dr. Diamantouros, Pantelis | 1. Interventional (PCI | TAVI) | LHSC | Generic Form | Phone: 519-663-3329 Fax: 519-434-3278 | Fax Consult |
| Dr. Garg, Pallav | 1. Interventional | LHSC | Generic Form | Phone: 519-663-3627 Fax: 519-663-2997 | Fax Consult |
| Dr. Jablonsky, George | 1. Interventional | LHSC | Generic Form | Phone: 519-663-3266 Fax: 519-434-3278 | Fax Consult |
| Dr. Lavi, Shahar | 1. Interventional | LHSC | Generic Form | Phone: 519-663-3611 Fax: 519-663-3117 | Fax Consult |
| Dr. Sridhar, Kumar | 1. Interventional | LHSC | Generic Form | Phone: 519-663-3474 Fax: 519-663-2997 | Fax Consult |
| Dr. Teefy, Patrick | 1. Interventional (PCI | TAVI) | LHSC | Generic Form | Phone: 519-663-3075 Fax: 519-663-3516 | Fax Consult |
| Dr. Davey, Ryan | 1. Heart Failure 2. Cardiac Transplant 3. Pulmonary HTN | LHSC | Generic Form | Phone: 519-663-3428 Fax: 519- 663-3764 | Fax Consult |
| Dr. De, Sabe | 1. Heart Failure | LHSC | Generic Form | Phone: 519-663-3428 Fax: 519- 663-3764 | Fax Consult |
| Dr. McKelvie, Robert | 1. Heart Failure 2. Cardiac Rehab | LHSC | Generic Form | Phone: 519-646-6175 Fax: 519-646-6139 | Fax Consult |
| Dr. Smith, Stuart | 1. Heart Failure 2. Cardiac Transplant 3. Cardio-Oncology | LHSC | Generic Form | Phone: 519-663-3428 Fax: 519- 663-3764 | Fax Consult |
| Dr. Dias, Bryan | 1. Cardio-Oncology | LHSC | Generic Form | Phone: 519-663-3483 Fax: 519-663-3499 | Fax Consult |
| Dr. Boughner, Derek | 1. Internal Medicine – Cardiology | LHSC | Generic Form | Phone: 519-663-3262 Fax: 519-434-3278 | Fax Consult |
| Dr. Mathew, Andrew | 1. General Cardiology 2. Cardiac Rehabilitation | LHSC | Generic Form | Phone: 519-663-3120 Fax: 519-663-3578 | Fax Consult |
Pediatric Physicians
| Pediatric Physicians | Subspecialty / Interest | Location | Form | Contact | Information |
|---|---|---|---|---|---|
| Dr. Grattan, Michael | 1. Pediatric Cardiology | LHSC Victoria Hospital | Generic Form | Phone: 519-685-8237 Fax: 519-685-8584 | Fax Consult |
| Dr. Norozi, Kambiz | 1. Pediatric Cardiology 2. Congenital Heart Defects | LHSC Victoria Hospital | Generic Form | Phone: 519-685-8237 Fax: 519-685-8584 | Fax Consult Speaks German and Persian |
| Dr. Rosenberg, Herschel | 1. Pediatric Cardiology 2. Fetal Echo | LHSC Victoria Hospital | Generic Form | Phone: 519-685-8237 Fax: 519-685-8584 | Fax Consult |
| Dr. Welisch, Eva | 1. Pediatric Cardiology | LHSC Victoria Hospital | Generic Form | Phone: 519-685-8237 Fax: 519-685-8584 | Fax Consult Speaks French, German, Spanish |
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