Use this online form to refer a patient to Heart and Health Clinic Cardiology or Internal Medicine for either of our clinic locations.

Alternatively, please download and send the referral form by email or fax.

Central Booking Line
T: (289) 760-9550
F: (905) 296-3858
E: info@heartandhealthclinic.ca

Clinic Locations

70 King St E, Lower Level
Stoney Creek, ON L8G 1K2

11 Cross St
Hamilton, ON L9H 2R3

1927 Ironoak Way, Unit 12
Oakville, ON L6H 0N

Patient Name

First Name

Last Name

Health Card Number

Patient Date of Birth

YYYY

Patient Email

Patient Phone

(###)

###

####

Reason for Referral

Cardiology & Internal Medicine

Shortness of Breath

Palpatations

Abnormal ECG

MINS Work Up

Chest Pain

Syncope

Hypertension

Dizziness

Arrythmia

Preclampsia

Diabetes

Other

Service(s) Requested

Cardiology Consultation

Internal Medicine Consultation

Echocardiogram

Stress Echocardiogram

Contrast Echocardiogram (Definity)

Transthoracic Echocardiogram

Preoperative Consultation

Holter Monitor - 24 Hour

Holter Monitor - 72 Hour

Holter Monitor - 7 Days

Other

If Other, please indicate here:

Clinical Information

Referring Physician Name

Referring Physician's Billing Number *

Referring Physician's Fax Number

Referring Physician's Signature

Type your first and last name below to act as your e-signature for the purpose of this referral.

Thank you for submitting your referral. We aim to reach out to all patients to schedule their appointment within one business day.

Heart and Health Clinic

Central Booking Line
T: 289-760-9550
F: 905-296-3858
E: info@heartandhealthclinic.ca

Opening Hours - All Locations
Monday - Friday: 8:30 AM - 4:30 PM
Saturday: 8:30 AM - 2:00 PM
Sunday: Closed

Hamilton - Stoney Creek Clinic
70 King St E, Lower Level
Stoney Creek, ON L8G 1K2

Hamilton - Dundas Clinic
11 Cross St
Hamilton, ON L9H 2R3

Welland Clinic
3 Cross St, Unit 301
Welland, ON L3B 5X6

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Online Referral

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Email Address

Thank you!