Discharge Referral for Consideration to Cardiac Rehabilitation (CR)
Patient Information
Patient’s name
Medicare#/ PPRN#
Birthdate/Age
Phone number
Family Physician
Referring
Physician
Cardiologist
Referral Date
Address
Referral Dx: Patients with
following diagnosis are eligible
for Referral.
Stable angina/CAD
MI/ACS
PCI/Stent(s)
CABG
Valvular Disease
Valve Repair/Replacement
Heart Failure/Cardiomyopathy
Stable cardiac arrhythmia’s
Permanent pacemaker/AICD
Congenital heart disorder
Heart transplant
Those on wait- list for CABG
requiring risk factor reduction i.e.
smoking cessation; weight loss
√ all that
apply this
admission
Please Select applicable Risk
Factors and/or Co-morbidities
√ all
that
apply
Smoking
Hypertension
Dyslipidemia
Diabetes
Obesity
Peripheral vascular disease
Left Ventricular dysfunction
COPD/Asthma/Lung Disease
Stroke
Arthritis
Aneurysm resection/repair
Renal Failure
Depression
Mobility Issues
NOTES:
Cardiac Rehab (CR) Program  shaded area. Note: Programs are not available in the
Woodstock, Plaster Rock or Perth areas
Saint John
Fredericton
St. Quentin
Fax 506-452Fax 506-2355677
7201
Hampton
Grand Falls
Campbellton
Fax 506- 473Fax 506-7897400
5240
Sussex
Edmundston
Fax 506-7392708
Caraquet
Fax 506-7262226
Miramichi Hosp.
Fax 506-623-6153
The Moncton Hosp
Fax 506-857-5796
Bathurst
Fax 506544-3989
St. Stephen
Fax 506465-4418
Georges Dumont Hosp
– CEPS
Fax 506-858-3780
1
Date Emailed:
By: