PATIENT INFORMATION	
Patient Name:      <PtFullName>	
Address:                 <PtStreet> <PtCity> <PtPostcode>		
Date of Birth:         <PtDoB>	
Phone No 	           Mob:	<PtPhoneMob>	Wk: <PtPhoneWk>	H: <PtPhoneH>	
 Medicare No: 	<PtMCNo>	

CARDIAC INVESTIGATIONS REQUESTED:				                                            
Echocardiogram (Echo) with ECG and Report	<Echocardiogram with ECG and Report>	
Echocardiogram (Echo)	<Echocardiogram>	
ECG and Report	<ECG and Report>	
Holter Monitor with ECG and Report	<Holter Monitor with ECG and Report>	
Holter Monitor   	<Holter Monitor>	
Event Monitor with ECG and Report 	<Event Monitor with ECG and Rweport>	
Event Monitor 	<Event Monitor>	
Ambulatory Blood Pressure Monitor	<ABP Monitor>	
Stress Echo Treadmill* (SET) with Baseline Echocardiogram	<Stress Echo>	
Stress Echo Dobutamine* (SET) with Baseline Echocardiogram	<DOB Stress Echo>	
Exercise Stress Testing* (Treadmill)	<Exercise Stress Test>	
	<Cardiac Investigations requested - Urgent> Urgent 	
	 
*Important Note: For treadmill and Dobutamine stress testing, patients should discontinue Beta Blockers, Digoxin, Veraparmil
and Diltiazem 48hours prior to testing

CARDIAC CONSULTATION:
<Select Cardiologist>
							 
CLINICAL NOTES:
<Clinical notes>

Current Prescription:
<SelectedRx>                 	
Medical history
<SelectedPMH>			
		
REFERRING DOCTOR:
Referring Doctor: 	<DrName>                 		Referring Doctor's Signature:	
Provider No:             <DrProviderNo>    

<DrAddress>         
Tel:  <DrPhone>	Fax:  <DrFax>	Email: <DrEmail>
Date: <TodaysDate>     				
Copy of Report to:
<Copy to Doctor:>    

REPORT PREFERENCE:

ELECTRONIC (HEALTHLINK) <ELECTRONIC>  FAX <FAX>  MAIL <MAIL>