Patient Surname: 	<<Patient Demographics:Surname>>
Patient First Name:	<<Patient Demographics:First Name>>
Date of Birth:		<<Patient Demographics:DOB>>
Address:		<<Patient Demographics:Full Address>>
Home Phone:		<<Patient Demographics:Phone (Home)>>
Mobile Phone:	<<Patient Demographics:Phone (Mobile)>>
Medicare No:		<<Patient Demographics:Medicare Number>>	
REFERRAL FOR:	REFERRAL TO:	
Bulk Billed Test:
Patient must have a Valid & Current Medicare Card

   Echocardiogram
   Holter Monitor
Patient Pays On Day of Appointment:
Phone Heart Rx on 4031 2188 for Current Fees

   Cardiologist Consultation
   Electrophysiologist Consultation
   Paediatric Cardiologist Consultation
   Exercise Stress Test (EST) with Consultation
   Exercise Stress Echo (ESE) with Consultation
   ECG
   Ambulatory Blood Pressure Monitor (ABPM)
   Transoesophageal Echo (TOE) at CPH
   Coronary Angiogram +/- PCI at CPH	   First Available Cardiologist    

Or to Doctor: …………………………………………

Clinical Information:

  	Breathlessness
  	Chest Pain
  	Palpitations
  	Arrhythmia
  	Dizziness
  	Syncope
  	Smoker ……………………………………….
  	Previous PCI .………………………………
  	Pacemaker ………………………………….
ECG:     NORMAL   ABNORMAL  Attach If Abnormal
ABILITY TO WALK ON A TREADMILL:   YES     NO 
If no, reason why: ………………………………………	
Clinical Details:  <<Summary:Progress Note (Current)>>

<<Doctor:Name>>
<<Doctor:Provider Number>>
<<Doctor:Full Address>>
<<Doctor:Phone>>
<<Miscellaneous:Date (short)>>