PATIENT DETAILS	Date of Birth: <<Patient Demographics:DOB>>	
Name: <<Patient Demographics:Full Name>>	Telephone: <<Patient Demographics:Phone (Mobile)>>	
Address:<<Patient Demographics:Address>>	Medicare Number: <<Patient Demographics:Medicare Number>>	
	
REQUEST FOR	 CLINICAL INDICATION   (please ticket at least one indication for each study requested                                                                                                   to ensure Medicare rebate compliance for your patient) 	
[ ] Echocardiogram 
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's no out of pocket expense. 	[ ] Suspected heart condition (GPs use this indication) 
[ ] Valvular dysfunction 
[ ] Known heart failure or structural heart disease 
[ ] Congenital heart disease 
[ ] Other ~ (please note below - cardiologist input required prior)
	
[ ] Stress Echocardiogram  
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. 	[ ] 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 with symptoms suggestive of ischaemia which are not  controlled with medical               therapy or new symptoms 
[ ] Pre-operative assessment 
[ ] Other ~ (please note below- cardiologist input may be required) 	
[ ] ECG Stress Test 	[ ] Assessment for cardiac ischaemia 
[ ] Other ~  (we recommend Stress Echo for other clinical indications) 	
      [ ] 24 hour Holter Monitor 
  [ ] 3 day Holter Monitor
  [ ] 5 day Holter Monitor 
  [ ] 7 day Holter Monitor   
  Holter @ Home Available* 	[ ] Syncope 
[ ] Pre-syncopal episodes 
[ ] Palpitations
[ ] Possible asymptomatic arrhythmia(eg AF or stroke investigation) 
[ ] Other (please note below) 	
  [ ] 24hour BP Monitor
  BPMonitor @ Home Available*
  Monitoring of known hypertension is not rebated by                   Medicare$100 fee applies 	
[ ] Suspected hypertension
[ ] Monitoring of pre-existing hypertension
[ ] Other (please note below) 
	
  [ ] Electrocardiogram 	[ ] 12-lead ECG trace and report 
[ ] Report only (please provide trace with your referral)	
       [ ] CT Coronary Angiogram 
                      (includes calcium score) 	[ ] Cardiologist consultation^ (compulsory -please tick this box) 
	
  [ ] RAPID ASSESSMENT 
       CHEST PAIN CLINIC^ 	  URGENT SAME DAY CONSULT APPOINTMENT - PH. 9789 6011 OR OUR REFERRER HOTLINE 
  Doctor or clinic staff please call directly to book for this appointment or to speak with our on-call cardiologist. 	
       [ ]  Cardiologist Consultation^                  Referral for 2nd opinions welcome

                                                     Referring Doctor Signature:
                                                                                          Name:
                                                                      Provider Number:                                                                                           copies to:	  Clinical notes, indication, patient history 
  (for tests,ticking a box above will suffice): 

<<Doctor:Name>>	

<<Doctor:Provider Number>>	

	
 CLINIC LOCATIONS - ALL TESTS BULK BILLED AT ALL LOCATIONS
FRANSKTON Nepean Specialist Centre - Suite 7, 525 McClelland Dve                                      CRANBOURNE Cranbourne Specialist Centre - Suite 2, 146 High St
MORNINGTON Mornington Special Centre - 1050 Nepean Hwy                                                  BERWICK Berwick Spcecialist Centre -34 Paternoster Lane
ROSEBUD Rosebud Specialist Centre - 1385 Point Nepean Road                                              PATTERSON LAKES Bayside Specialist Centre - 29/21 Thompson Rd
HASTINGS Westernport Specialist Centre - Suite 5, 184 Salmon St                                           BRIGHTON Bay Street Specialist Centre - Suite 4,214 Bay Street 
WONTHAGGI White Road Suites - 231 White Road                                                                    CAPE WOOLAMI Suite 4, 13-18 Vista Place 	
We're pleased to BULK BILL all tests where patients meet Medicare eligibility criteria ^ Cardiologist Consultations are bulk billed in Hastings and Cranbourne.
*@ Home Holter and BP monitors available in over 200 suburbs. This service attracts a $30 travel fee (except for DVA patients) - visit our website for more information
~ To ensure Medicare compliance for bulk billing and patient rebate some tests may require cardiologist input where 'other' indication box is ticked. We will arrange this if needed.