PATIENT DETAILS
Patient Name: 	<PtFullName>						Ethnicity: <PtEthnicity>
Address:		<PtStreet> <PtPOCity> <PtPostcode>
Date of Birth:	<PtDoB>  						Email: <PtEmail>
Phone No 		Mob: 	<PtPhoneMob> 	Wk: 	<PtPhoneWk> 			H: <PtPhoneH>
Medicare No: 	<PtMCNo>			MC Exp: <PtMCExpiry>    MC Line: <PtMCLine>      UMRN: <PtRecordNo>
Aboriginal Medical Service: 	<Name of Aboriginal Medical Service>  		Book through Aboriginal Medical Service?   <Book through Aboriginal Medical Service?>
Other: <Other patient contact information> 	

Book patient for cardiology consult?   <Book cardiology consult?>

CLINICAL NOTES:					
<Clinical notes>

ARF/RHD:  <Does patient have ARF/RHD?>							

CARDIAC INVESTIGATIONS REQUESTED				PREFERRED LOCATION	       URGENT
Echocardiogram (Echo) with ECG and Report	<Order Echocardiogram with ECG and Report>	<Echo Locations	>	<Is Echo URGENT?>	
Echocardiogram (Echo)	<Order Echocardiogram>	<Echo Locations	>	<Is Echo URGENT?>	
ECG and Report	<Order ECG and Report>	<Echo Locations	>	<Is Echo URGENT?>	
Holter Monitor with ECG and Report
	<Order Holter Monitor with ECG and Report>	<Holter Locations>	<Is Holter URGENT?>	
Holter Monitor   	<Order Holter Monitor>	<Holter Locations>	<Is Holter URGENT?>	
Event Monitor with ECG and Report 	<Order Event Monitor with ECG and Rweport>	<Event Locations>	<Is 7 day Event URGENT?>	
Event Monitor 	<Order Event Monitor>	<Event Locations>	<Is 7 day Event URGENT?>	
Ambulatory Blood Pressure Monitor
	<Order ABP Monitor>	<ABP Locations>	<Is ABP URGENT?>	
Stress Echo Treadmill* (SET) with Baseline Echocardiogram
	<Order Stress Echo>	<Stress Echo Locations>		<Is Stress Echo URGENT?>	
Stress Echo Dobutamine* (SET) with Baseline Echocardiogram	<Order DOB Stress Echo>	<Dobutamine Locations>		<Is Dobutamine URGENT?>	
Exercise Stress Testing* (Treadmill)	<Order Exercise Stress Test>	<Stress Test Locations>	<Is Stress Test URGENT?>	
*Important Note: For diagnostic exercise testing, patients should discontinue Beta Blockers, Digoxin, Verapamil & Diltiazem 48hrs prior to testing.

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 of Report to>    
 
KAMS <Report copy to KAMS>  	BRAMS <Report copy toBRAMS>  	DAHS <Report copy toDAHS>  	YYMS <Report copy toYYMS>  	OVAHS <Report copy to OVAHS>
BDP <Report copy to Broome Doctor's Practice>         	BMC <Report copy to Broome Medical Centre>            	KMG <Report copy to Kimberley Medical Group>     	KM <Report copy to Kununurra Medical>
                                                                                  
REPORT PREFERENCE (Electronic (HEALTHLINK) / Fax):   <How would you like to receive your report?>