AMARDEEP S. MANGAT MD FRCPC * NAZIA HOSSAIN MD FRCPC * CAMILLE CLARKE MD FRCPC * STEPHEN BRAZEAU MD FRCPC & ASSOCIATES Please enable JavaScript in your browser to complete this form.AROGA LIFESTYLE MEDICINE (COMMON ELIGIBLE CONDITIONS): *Obesity and Obesity Related Disease NonDiabetes Type 2 DyslipidemiaAlcoholic Fatty Liver Disease and NASH HypertensionCoronary Artery Disease Polycystic Ovarian Syndrome Eczema/PsoriasisCerebrovascular DiseaseAtrial FibrillationOtherThe Aroga Lifestyle Medicine specialist consult treats chronic disease with evidence-based & guideline-based intensive-yet-sustainable lifestyle change interventions as primary treatment and when necessary provides pharmacological treatment. Consults and follow ups combine our medical specialist expertise with in-house allied health professionals to optimize outcomes and provide patients with the tools necessary to take control of their own bodies. This specialist consult is fully covered by OHIP in ON.OtherCARDIAC DIAGNOSTICS *24-Hour BP MonitorTreadmill ConsultFitness To Exercise Holter TestingPalpitations ConsultSyncope ConsultElectrocardiogram Chest Pain ConsultOtherOtherGENERAL INTERNAL MEDICINE and PERIOPERATIVE MEDICINEReason for referral (please append a referral letter with details):If Pre-op, what is the proposed OR date:CLICK ONE: *VERY URGENT (within days) URGENT (within 3 weeks) NONURGENT (>3 weeks)ANEMIA/HEMATOLOGICAL DISORDERS *Anemia/Iron Deficiency ConsultationGeneral Hematological DisorderIron Infusion (private service, infusion fee applicable)***Please ensure the patient provided with a prescription for Venofer or Monoferric and order to infuse PATIENT REFERRAL NAME (FIRST/LAST) *Select Gender *MaleFemaleHEALTH CARD NUMBER *DATE OF BIRTH *TELEPHONE *CELL PHONE *ADDRESS *EMAIL *DIAGNOSIS *REFERRING MD *OHIP # *REFERRING *REFERRING PRACTITIONER *COPIES TO *MD Signature * Click or drag a file to this area to upload. Please provide and append as much pertinent data as possible. Eg: Lab Reports, Consultant Reports, Imaging Reports, etc. You will get notified about your patient’s booked appointment time and date. All consult notes will be sent to your office via fax. PLEASE SEND ALL REFERRALS TO: 289-726-2032 Submit
