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Main Line:
(306)-757-2478
Fax:
306-585-3993
Home
Services
Physicians
Patients
Forms
Cardiology Consultation
Echocardiography
Stress Echocardiography
Exercise Stress Test
Holter ECG Monitoring
Cardiac Loop Monitoring
ABI Testing
About Us
FAQs
Request for Stress Echocardiography
Only Health -Care Providers (Medical Doctors & Nurse Practitioners) May Submit a Request!
Request for Stress Echocardiography
First Name
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Last Name
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Sex
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Female
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Patient Health Number
Phone
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Date of Birth
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Email
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Address
Address
Address
City
City
State/Province
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Zip/Postal
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Diagnosis / Clinical History
*
Chest pain/Coronary Disease
Dyspnea evaluation (cardiac vs. non-cardiac)
Arrhythmia
Preoperative Assessment
Mitral Regurgitation (ischemic vs non-ischemic MR)
Mitral Stenosis (exercise pressure gradient)
Cardiomyopathy (dynamic assessment)
Non-diagnostic Exercise Stress Test
Diastolic Stress Testing
Pulmonary hypertension (exercise-induced)
Valvular Heart Disease Assessment
Prosthetic valve assessment
Notes
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Study Date
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