Echocardiography Specialist Centre | REQUISITION

FOOTHILLS PROFESSIONAL BUILDING Central Booking (403)541-1200

Suite 148, 1620 - 29th Street NW, Calgary, AB T2N 4L7 Fax (403) 210-8377
Appointment Required
Date of Issue  DD/MM/YY Appointment Date  DD/MM/YY

Patient Information  Place patient label here

Name  Phone (Res)

DOB DD/MM/YY  M   F Ht. Wt. Work Cell
Address  AHC# 
City/Province    Postal Code  WCB# 

EXAM REQUESTED TO LOOK FOR SIGNIFICANT CLINICAL HISTORY

REFERRING SYMPTOMS PATHOLOGIES

 Dysprea  TIA/Stroke Murmur Tricuspid

 Oedema  Syncope  Systolic  Stenosis
 Chest pain   Fatigue  Diastolic  Regurgitation
 CHF with Pulmonary Edema Aortic Cardiomyopathy
 CHF with predominant right heart failure   Stenosis  Dilated
Prosthectic valve  Insufficiency  Hypertrophic
 Specify type  Bicuspid  Restrictive
 Size Mitral  Pulmonary Hypertension
 Age  Stenosis  Systemic Hypertension
Congenital Heart Disease  Insufficiency  Diastolic Function
 Specify  Prolapse  Pericardial Effusion
Other Pulmonary valve disease  Constrictive Pericarditis
 Specify  Stenosis  Remote MI
 Regurgitation  Serial EF on Chemotherapy
REFERRING PHYSICIAN
 Aortic Aneurysm
Physician name
EFW ECHOCARDIOGRAPHY SPECIALIST CENTRE PROTOCOL
Signature 
Additional report to: 
Call/Fax emergency report to:
Physician phone  
Physician address

PLEASE SEND MORE REQUISITIONS

QUANTITATIVE ECHOCARDIOGRAM Official diagnostic imaging provider for:

The EFW Echocardiography Specialist Centre performs high

resolution Quantitative Echocardiograms. This exam provides
your doctor with a comprehensive report detailing your heart
and its:

• overall size as well as details of each chamber

• overall strength as well as strength of specific muscles

• precise blood flow measurements in each chamber and

across the valves
TM

• pumping mechanics; and

• overall assessment of your heart health. EFW is a proud partner of:

PATIENT INSTRUCTIONS
• Please arrive 15 minutes in advance of your appointment
time.

• Confirming your identification is essential to ensure accurate

medical records and for your protection and security.

• You will be asked at EACH VISIT to provide a VALID HEALTH

CARE CARD and PICTURE ID.

• If you do not have your card you may be asked to return for
your examination.

• Please bring your requisition with you.

• Phone to cancel if unable to keep booked appointment. Central Booking  (403) 541-1200
• Please notify reception if you are diabetic. Fax  (403) 210-8377
• Patients suspecting pregnancy should consult their efwrad.com
physician before exam date.

• Please be prepared to be at the clinic for 1.5 - 2 hours for ECHOCARDIOGRAPHY

this appointment. SPECIALIST CENTRE
Foothills Professional Building
Suite 148, 1620 - 29th Street NW,
SEPARATE REQUISITIONS FOR:
Calgary, AB T2N 4L7
General Diagnostic, Pediatric Ultrasound, MRI,
or Pain Management & Spine Interventional Please go to efwrad.com for maps & directions
Available as PDF downloads on our website,
efwrad.com, or call (403) 717-1816

Notice: The personal health information that you provide to EFW is collected, used and disclosed in accordance with the provisions of the Health Information Act (HIA), and
is used to provide diagnostic, treatment and care services to you, and to bill Alberta Health Care for services provided. For more information, please contact the EFW Privacy
Officer at (587) 470-6449.

3202018