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Peterborough Regional Vascular Health Network (VHN)
Is this an emergency? Patient Education & Resources Community Involvement and Events Authoritative Links & Sponsors
Is this an emergency? Patient Education & Resources Community Involvement and Events Authoritative Links & Sponsors

Vascular Risk Optimization Clinic (VROC)
WEB FORM

I am:
 Male 40 - 75 years old
Female 50 - 75 years old

NOT ALREADY Prescribed All "Lifesaver Drugs"
(You may be on some of these medications, just not all of them)

Statin for Cholesterol
ACE Inhibiter (Drugs ending in "PRIL")
ARB (Drugs ending in "SARTAN")
Aspirin/ Plavix / Ticlid

Do not have an established diagnosis
of Heart Disease, Stroke or Vascular Disease

Do not have a Cardiologist or an Internal
Medicine Specialist looking after you

OR
In an exceptionally high risk occupation, such as fire fighting.

From a family with an exceptionally high incidence of vascular disease.

Name *
Sex *
Address *
City *
Postal Code *
High Risk Occupation * i.e. Fire Fighter
Date of Birth * Day   Month   Year
CurrentAge *
E-mail
Phone *
Business #
Cell Phone
Family Dr. *
Dr.'s Name
Dr.'s Address
Dr.'s Postal Code
Dr.'s Tel #
* Indicates a required field.

List All Medications you now take:


Thank you for taking the time to complete this form.
A nurse will review your submission and you can expect a letter, with appointment times, in the mail.
If the nurse has questions or needs clarification regarding the information you have given us,
you will be called at the number you provided.

Read our Privacy Policy here


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