DR JAY BAUMWOL	
DR MICHAEL MUHLMANN	

DR MATTHEW BEST	
PROF GERRY O'DRISCOLL	

DR MICHAEL DAVIS	
DR ANNE POWELL	

DR ATHULA KARU	
DR JAMIE RANKIN	

DR ARIEH KEREN	
DR SHARAD SHETTY	

DR SUSAN KURUVILLA	
DR NIK STOYANOV	

TESTING APPOINTMENTS& 	
GENERAL ENQUIRIES: 6314 6833  
PLEASE FAX TO : 6314 6888	

PATIENT INFORMATION	
Patient Name:	<<Patient Demographics:Full Name>>	
Address:	<<Patient Demographics:Full Address>>	
Date of Birth:	<<Patient Demographics:DOB>>	
Phone No:	Mobile:	
<<Patient Demographics:Phone (Mobile)>>	

Work:	
<<Patient Demographics:Phone (Work)>>	

Home:	
<<Patient Demographics:Phone (Home)>>	

Medicare Number:	<<Patient Demographics:Medicare Number>>	

CARDIAC INVESTIGATIONS REQUESTED:	

	
Cardiology Consult

	
Event Monitor with ECG and Report

	

Echocardiogram (Echo) with ECG and Report

	
Event Monitor 

	

Echocardiogram (Echo) 

	
Ambulatory Blood Pressure Monitor

	

ECG and Report

	
Stress Echo Treadmill* (SET) with Baseline Echocardiogram

	

Holter Monitor with ECG and Report

	
Stress Echo Dobutamine* (SET) with Baseline Echocardiogram	

	
Holter Monitor 

	
Exercise Stress Test* (Treadmill)

* For diagnostic exercise testing, patients should discontinue B          blockers, digoxin, verapamil and diltiazem 48 hours prior to testing	

	

CLINICAL NOTES:	
	
HISTORY LIST	
<<Clinical Details:History List>>	
MEDICATION LIST	
<<Clinical Details:Medication List>>	
REFERRING DOCTOR:	
Referring Doctor:	<<Doctor:Name>>	Referring Doctor's Signature:		
Provider No:	<<Doctor:Provider Number>>	
Address:	<<Doctor:Full Address>>	
Tel:	<<Doctor:Phone>>	Fax:	<<Doctor:Fax>>	
Email:	<<Doctor:E-mail>>	Date:	<<Miscellaneous:Date (short)>>	

Copy of Report to:	
<<Addressee:Full Details>>	

REPORT PREFERENCE:	

ELECTRONIC (HEALTHLINK)

	FAX

	
MAIL		

	URGENT