Referral Cardiology APPT DATE/TIME PATIENT NAME DATE OF BIRTH ADDRESS PHONE & EMAIL CURRENT MEDICATIONS PATIENT HISTORY ● Hypertension ● Dyslipidaemia ● Family history ● Diabetes ● Smoker CLINICAL DETAILS REFERRAL FOR ● Cardiologist consultation ● Rapid access chest pain assessment ● Heart failure management clinic ● Arrhythmia management clinic INVESTIGATIONS REQUESTED ● 1. Echocardiogram ● 2. Exercise stress test ● 3. Stress echo ● 4. Dobutamine stress echo ● 5. Holter monitor (24 hour) ● 6. Patient Activated Recorder (7 day event monitor) ● 7. Ambulatory BP Monitor (not covered by Medicare) ● 8. Resting ECG 083_11/V05/July19 [email protected] | genesiscare.com REFERRING DOCTOR COPY TO Your doctor has recommended that you use GenesisCare for your test. Should you wish to use another provider, please discuss this with your doctor first. To prepare for your test, please visit genesiscare.com/cardiology Formerly: SIGNATURE/DATE and
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APPT Referral Cardiology - GenesisCare · Dr Vincent Paul T 9480 3060 Dr Peter Purnell T 9400 6111 Dr Pradyot Saklani T 9480 3060 Dr Nigel Sinclair T 9480 3060 Dr Isabel Tan T 9400
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Referral CardiologyAPPT DATE/TIME
PATIENT NAME DATE OF BIRTH
ADDRESS PHONE & EMAIL
CURRENT MEDICATIONS PATIENT HISTORY
● Hypertension
● Dyslipidaemia
● Family history
● Diabetes
● Smoker
CLINICAL DETAILS REFERRAL FOR
● Cardiologist consultation
● Rapid access chest pain assessment
● Heart failure management clinic
● Arrhythmia management clinic
INVESTIGATIONS REQUESTED
● 1. Echocardiogram
● 2. Exercise stress test
● 3. Stress echo
● 4. Dobutamine stress echo
● 5. Holter monitor (24 hour)
● 6. Patient Activated Recorder(7 day event monitor)
● 7. Ambulatory BP Monitor(not covered by Medicare)
Your doctor has recommended that you use GenesisCare for your test. Should you wish to use another provider, please discuss this with your doctor first.
To prepare for your test, please visitgenesiscare.com/cardiology