Patient Details	

Patient Name:	  	
Postal Address:	  	State:	  	Post Code:	  	
Date of Birth:		Phone Number:	  	
Medicare Number:	  			

Examination Required (All testing is bulk billed)	

•	Echocardiogram	•	Exercise Test 
(Includes baseline ECG)	•	Holter Monitor	
•	Stress Echo (Treadmill) 
(Includes baseline Echo)	•	Stress Echo (Exercise Bike) - Stirling Only 
(Includes baseline Echo)	•	Ambulatory BP Monitor 
(Not covered by Medicare)	
•	Event Monitor
	•	ECG	•	CT Coronary Angiogram
(Includes Specialist review)	

•	Please Indicate if this appointment is Urgent
•	Please book patient for a Cardiology Consult if indicated by results

Cardiology Consultation	

•	A/Prof Michael Nguyen
Interventional Cardiologist	•	Dr Justin NG
Cardiologist / Electrophysiologist	•	Dr Hassan Kamalddin
Consultant Cardiovascular Physician	
•	Dr Robert Harvey
Interventional Cardiologist			

Clinical Details	

Medical History / Medications:

Specific Clinical Query?

Referring Doctor	

Name: 	Provider Number: 	
Signature: _____________________
	Date: 	
Practice Name: 	Contact Number: 	
Health Link EDI: 		

Copy of the report to: ________________________________________

Locations	

 
Nedlands

Suite 307 (Level 3)
Hollywood Consulting Centre
91 Monash Avenue
Nedlands WA 6009
(Gate 5 Entrance)	
Murdoch

Suite 55 (Level 3)
Wexford Medical Centre
3 Barry Marshall Parade
Murdoch WA 6150	
Joondalup

Suite 8 (Level1)
Sanori House
126 Grand Boulevard
Joondalup WA 6027	
			
Mandurah

32 Minilya Parkway
Greenfields WA 6120	Albany

Testing:
Zone 2, Albany Hospital
Warden Avenue
Albany WA 6330

Consulting:
102 Aberdeen Street
Albany WA 6330	Stirling
Testing Only

12 / 732 Karrinyup Road
Balcatta WA 6021	
			
Midland
Testing Only

34 Railway Parade
Midland WA 6056
(Located inside Painwest)	Rockingham
Testing Only

35 Elenora Drive
Cooloongup WA 6168
(Located inside Western Obstetrics)