FOR APPOINTMENTS CALL (07) 5647 6001

            
Phone: 07 5647 6001  Fax: 07 5647 6016

Robina HQ Building: Suite 21 (Level 2) 58 Riverwalk Avenue Robina 4226

POTTSVILLE: 5 Coronation Avenue Pottsville 2489
										   (Resting echo/24HBP/ Holters only)
       
Date of Referral: <TodaysDate>
		
Patient Details:	Referring Doctor:	
Name:  <PtFullName>    (D.O.B.: <PtDoB>)	<DrName>	
Medicare:  <PtMCNo> - <PtMCLine>  Exp  <PtMCExpiry>	Provider No. <DrProviderNo>	
Phone: <PtPhoneMob>  or   <PtPhoneH>	<UsrAddress>	
Address: <PtStreet> <PtCity> <PtState> <PtPostcode> 	Phone: <UsrPhone>	

Investigation/s Requested:

<Resting Echo> Resting Echocardiogram	<Stress Echo> Stress Echocardiogram	<Holter monitor>  Holter monitor (24 hours)	
<Rooti Patch - 5 days> Rooti Patch	<ABI>  ABI	<24 Hr BP Monitor> 24 hour BP Monitor	

Consultation:   
<Cardiology Consultation?> 

 Clinical History/Indication:

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

Past Medical History
<SelectedPMH>

Medications
<SelectedRx>

Allergies
<Reactions>

SIGNATURE:  ________________________________	<TodaysDate>	
              
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