FOR APPOINTMENTS CALL 1300 323 307

            
Varsity One Building
 Lakeside 1, Level 1 (Next to the Cafe)
1 Lake Orr Drive Varsity Lakes 4227
Phone 1300323 307
       
Date of Referral: <<Miscellaneous:Date (short)>>
		
Patient Details:	Referring Doctor:	
Name:  <<Patient Demographics:Full Name>> (D.O.B.: <<Patient Demographics:DOB>>)	<<Doctor:Name>>	
Medicare:  <<Patient Demographics:Medicare Number>>  Exp  <<Patient Demographics:Medicare Expiry Date>>	Provider No. <<Doctor:Provider Number>>	
Phone: <<Patient Demographics:Phone (Mobile)>> or   <<Patient Demographics:Phone (Home)>>	<<Doctor:Full Address>>	
Address: <<Patient Demographics:Full Address>> 	Phone: <<Doctor:Phone>>	

Investigation/s Requested:

<<Resting Echo>> Resting Echocardiogram	<<Stress Echo>> Stress Echocardiogram	<<Holter monitor>> Holter monitor (24 hours)	
<<Rooti Patch>> Rooti Patch	<<ABI>> ABI	<<24 hour BP Monitor>> 24 hour BP Monitor	

Cardiology consultation  
 <<Cardiology Consultation? Please select>>

Clinical History/Indication:
Echo Indication (MBS Criteria): <<Echo Indication (MBS Criteria)>>
Stress Echo Indication (MBS Criteria): <<Stress Echo Indication (MBS Criteria)>> 
Additional Clinical History: <<Additional Clinical History>>

Past Medical History
<<Clinical Details:History List>>

Medications
<<Clinical Details:Medication List>>

Allergies
<<Clinical Details:Allergies/Adverse Reactions>>

SIGNATURE:  ________________________________	<<Miscellaneous:Date (short)>>	
                  
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