Patient Information
Surname: Santos
First Name: Maria
DOB: 1948-05-19
Gender: Female
HN PC: ON
Address (Line 1): 85 King St S
Mobile #: 519-555-0362
Home #: 519-555-0198
Email: maria.santos@example.com
[Optional] Additional Patient Information

Sex assigned at birth: Female
Pronouns: She/HerThey/Them
Preferred language: English
Best method of contact: Home

Accessibility concerns or disability

Wheelchair; Hearing impaired

Referral Details
Triage Considerations Requested Priority:
Routine

Service(s) Requested
Cardiology Consultation
Concern(s) / Indication(s) Triggering Referral
Select all that apply:


Congestive Heart Failure
Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations
77F, progressive exertional dyspnea and bilateral ankle edema x 2 months. BNP elevated at 480. CXR shows mild cardiomegaly. On furosemide 20mg with partial response. Please assess and advise on HF management.
Cumulative Patient Profile

Please delete any sensitive information you do not intend to share from the CPP
Current Problem List: Suspected CHF (onset Jan 2026) Hypertension Type 2 diabetes
Past Medical History: Left hip replacement (2020) Type 2 diabetes (2012)
Current Medications : Furosemide 20 mg PO daily Perindopril 4 mg PO daily Metformin 500 mg PO BID Empagliflozin 10 mg PO daily
Family History: Mother: CHF, deceased age 80
Allergies: NKDA
Referrer's Information
Site Name: Amplify Primary Care
Address (Line 1): 10248 Yonge St
Phone #: 416-555-5555
Fax #: 416-555-5555
Billing Number: 55554
Professional ID: 55555
Signed: Dr. Sean Sender
Role: Family Physician