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Atrial Fibrillation Clinic Name Royal Jubilee Hospital 1952 Bay Street Royal Block 3rd Floor Rm 343 Victoria B.C. V8R 1J8 Phone 250-370-8632 FAX NUMBER 250-595-1000 via Western Cardiology DOB M/F PHN MRN Address Telephone number REFERRAL FORM PLEASE NOTE ECG DOCUMENTATION OF AF IS REQUIRED Date Referring physician/NP please print Total pages Referred from Primary care Internist ED Other Please provide the following history AF diagnosis Check one Newly diagnosed Previously diagnosed Purpose of referral Check one Cardiologist assessment for Opinion Consultation and management Post-ablation follow-up Education Only no cardiologist assessment Symptoms when in AF Indications for referral Check all that apply Assistance with medication trials If cardiologist assessment requested request consult by Next Available Cardiologist wait times will vary to cardiologist C. Lane R* Leather P. Novak L* Sterns D. Massel AF treatment history med trials cardioversions ablations Cardiologist consult notes to be copied to please specify We require the following to process the referral Done 12 Lead ECG or Holter documenting AFIB Hematology Profile Electrolyte Panel Liver Function Renal Function Tests Thyroid Function BNP brain natriuretic peptide if symptoms of HF Other Available cardiac test results Current medication history Pending Other cardiac history Comments Physician/NP Signature Ph Pt. will be contacted by Western Cardiology for an appointment. For questions call 250-370-8632. AF CLINIC REFERRAL Dec* 2014 Stroke Risk Assessment http //www. ccsguidelineprograms. ca Definitions Might require lower dosing* AF atrial fibrillation or atrial flutter OAC oral anticoagulant ASA acetylsalicylic acid CAD coronary artery disease CCS Canadian Cardiovascular Society CHADS2 Congestive Heart Failure Hypertension Age Diabetes Stroke/Transient Ischemic Attack eGFR estimated glomerular filtration rate INR international normalized ratio NOAC novel oral anticoagulant NSAID nonsteroidal anti-inflammatory drug TIA transient ischemic attack. Reference 1. Verma A Cairns J Mitchell L et al CCS Atrial Fibrillation Guidelines Committee. 2014 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation* Can J Cardiol 2014 Oct 30 10 1114-30. Lane R* Leather P. Novak L* Sterns D. Massel AF treatment history med trials cardioversions ablations Cardiologist consult notes to be copied to please specify We require the following to process the referral Done 12 Lead ECG or Holter documenting AFIB Hematology Profile Electrolyte Panel Liver Function Renal Function Tests Thyroid Function BNP brain natriuretic peptide if symptoms of HF Other Available cardiac test results Current medication history Pending Other cardiac history Comments Physician/NP Signature Ph Pt. will be contacted by Western Cardiology for an appointment. For questions call 250-370-8632. AF CLINIC REFERRAL Dec* 2014 Stroke Risk Assessment http //www. will be contacted by Western Cardiology for an appointment. For questions call 250-370-8632. AF CLINIC REFERRAL Dec* 2014 Stroke Risk Assessment http //www. ccsguidelineprograms. ca Definitions Might require lower dosing* AF atrial fibrillation or atrial flutter OAC oral anticoagulant ASA acetylsalicylic acid CAD coronary artery disease CCS Canadian Cardiovascular Society CHADS2 Congestive Heart Failure Hypertension Age Diabetes Stroke/Transient Ischemic Attack eGFR estimated glomerular filtration rate INR international normalized ratio NOAC novel oral anticoagulant NSAID nonsteroidal anti-inflammatory drug TIA transient ischemic attack.