PATIENT DETAILS
Name:	<PtFullName>				Date of Birth:<PtDoB>
Telephone:<PtPhoneMob>			Address:<PtAddress>
Medicare:<PtMCNo>
REQUEST FOR:			CLINICAL INDICATION:
[   ] Echocardiogram		[   ]	Suspected Heart Condition (GPs use this indication)
				[   ]	Valvular dysfunction
				[   ]	Known heart failure of structural heart disease
				[   ] 	Congenital heart disease
				[   ]	Other ~ (please note indication below – cardiologist input required prior)
GPs are only able to refer this test every 2 years for Medicare rebate.  Please contact our office if you have had this, or a similar test previously to ensure there is no out of pocket expense.
[   ] Stress Echocardiogram	[   ]	Chest/Neck/Arm/Jaw/Shoulder pain or discomfort (typical or atypical)
				[   ]	Shortness of breath
				[   ]	Silent ischaemia suspected (eg diabetic, elderly or at risk patient)
				[   ]	Abnormal ECG consistent with coronary artery disease or ischaemia
				[   ] 	Known coronary artery disease
				[   ]	Pre-operative assessment
				[   ]	Other ~ (please note indication below – cardiologist input required prior)
GPs are only able to refer this test every 2 years and specialists every 12 months for Medicare rebate.  Please contact our office if you have had this or a similar test previously to ensure there is no out of pocket expense.
[   ] ECG Stress Test		[   ]	Assessment for cardiac ischaemia
				[   ]	Other ~ (please note indication below – cardiologist input required prior)
[   ] 24 hour Holter Monitor	[   ]	Syncope
[   ] 3 day Holter Monitor	[   ]	Pre-syncopal episodes
[   ] 7 day Holter Monitor	[   ]	Palpitations
				[   ]	Possible asymptomatic arrhythmia (eg AF or stroke investigation)
				[   ]	Other ~ (please note indication below – cardiologist input required prior)
[   ] 24 hour BP Monitor	[   ]	Suspected hypertension
				[   ] 	Monitoring of pre-existing hypertension
				[   ]	Other ~ (please note indication below – cardiologist input required prior)
Monitoring of known hypertension is not rebated by Medicare $100 fee applies
[   ] Electrocardiogram	[   ]	12-lead ECG trace and report
				[   ]	Report only (please provide trace with your referral)
[   ] CT Coronary Angiogram 	[   ]	Cardiologist consultation ^ (compulsory – please tick this box)
[   ] RAPID ASSESSMENT	[   ]	URGENT SAME DAY CONSULT APPOINTMENT
	CHEST PAIN CLINIC ^	     Doctor or clinic staff please call directly to book this appointment
[   ] Cardiologist Consult	[   ]	Clinical notes, indication, patient history

Referring Doctor Signature:

Referrer Name: <DrName>
Provider Number: <DrProviderNo>

Copies to:
FRANKSTON | MORNINGTON | ROSEBUD | HASTINGS | CRANBOURNE 
 BERWICK | PATTERSON LAKES | BRIGHTON | WONTHAGGI | CAPE WOOLAMAI 

We’re pleased to BULK BILL all tests for Medicare eligible patients. ^Cardiologist consultations are bulk billed in Hastings and Cranbourne.
Visit our website www.nepeancardiology.com.au or phone 97896011 to book your appointment
***PLEASE BRING THIS REFERRAL TO YOUR APPOINTMENT***