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Share Your One Heart Care Experience

We’d love to hear from you! Your feedback helps us provide compassionate, high-quality care. Please fill out the form below to share your experience.

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Submit Your Testimonial

We’d love to hear about your experience with One Heart Care! Please take a moment to share your feedback below.

Name: *

Role: *

Referring GP
Patient

Your Testimonial:

Note: Please keep your comments to 3–5 sentences. Your feedback may be lightly edited for clarity and formatting. Ensure your comments are honest, respectful, and do not include sensitive personal or medical information.

Layout Role: Checkboxes

Checkboxes *

*I consent to One Heart Care using my testimonial, including my name and feedback for marketing, promotional, and educational purposes on websites, social media, print, or other media. I understand that my testimonial may be edited for clarity or length, but my words will not be misrepresented. I confirm that I am providing this consent voluntarily and that I may withdraw it at any time by contacting One Heart Care.

Stay Updated

Stay informed with the latest news, updates, and advancements from One Heart Care.

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Name *

Email *

Name Checkboxes Email

I am a: *

Patient or Caregiver
Physician or Healthcare Provider

Checkboxes *

*I consent to receive email communications from One Heart Care, including news, updates, and information about services. I understand I can unsubscribe at any time.

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Collaboration Inquiry

We’re excited to hear from potential collaborators! Share your ideas below to explore ways we can advance cardiac care together.

Full Name: *

Business Email: *

Type of Organization: *

Medical
Technology
Other

Other Type of Organization Field

Organization: *

Phone Number *

Brief Description of Partnership Interest: *

(Please share how you envision collaborating with One Heart Care)

Organization: Disclaimer: of

Preferred Method of Contact: *

Email
Phone

Disclaimer: *

*I consent to One Heart Care using the information I provide to respond to my partnership inquiry. I understand my details will be handled securely and I may withdraw consent at any time.

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Submit Your Testimonial

We’d love to hear about your experience with One Heart Care! Please take a moment to share your feedback below.

Name: *

Role: *

Referring GP
Patient

Your Role: Testimonial:

Your Testimonial:

Note: Please keep your comments to 3–5 sentences. Your feedback may be lightly edited for clarity and formatting. Ensure your comments are honest, respectful, and do not include sensitive personal or medical information.

Checkboxes *

*I consent to One Heart Care using my testimonial, including my name and feedback for marketing, promotional, and educational purposes on websites, social media, print, or other media. I understand that my testimonial may be edited for clarity or length, but my words will not be misrepresented. I confirm that I am providing this consent voluntarily and that I may withdraw it at any time by contacting One Heart Care.

Please enable JavaScript in your browser to complete this form.

Telephone: 905-804-7000
Fax: 905-804-2250
Email: referral@oneheartcare.ca
Website: www.oneheartcare.ca

Patient Demographics

Name *

First

Last

Phone: *

DOB *

HCN: *

Version Code: *

Gender: *

Male
Female

Physician Information

Referred By*: *

Physician Billing No.*: *

Telephone*: *

Signature*: *

Clear Signature

Cardiac Diagnostics

Cardiac Diagnostics Checkboxes *

ECG
Echocardiography
Endocardial Enhancement Agent
Bubble Saline Contrast (Shunt Detection)
Holter Monitoring
Ambulatory Blood Pressure Test (fee $80)
Exercise Stress Test (GXT)
Stress Echocardiogram
Nuclear Myocardial Perfusion Imaging

Holter Monitoring Duration:

48 Hours
72 Hours
7 Days
14 Days

Echocardiography Types:

Endocardial Enhancement Agent
Bubble Saline Contrast (Shunt Detection)

Nuclear Myocardial Perfusion Imaging Choices:

Exercise
Persantine
Muga

Height:

Weight:

Urgent: *

Yes
No

Cardiology Consultations

Cardiology Consultations Checkboxes

Urgent
First Available
Consult if Abnormal Test only

With Dr. *

Clinical Information*

Clinical Information *

Consent Code: Clinical

Consent Disclaimer *

*By submitting this form, I confirm that I am a healthcare provider making this patient referral. I consent to One Heart Care collecting and using the information provided to process the referral and communicate regarding the patient’s care. I understand that the information will be handled securely and in accordance with One Heart Care’s Privacy Policy.