Patient Details	

Patient Name:	  <PtName>	
Postal Address:	  <PtPOAddress> <PtCity>	State:	  <PtState>	Post Code:	  <PtPostcode>	
Date of Birth:	  <PtDoB>	Phone Number:	  <PtPhoneH>	
Medicare Number:	  <PtMCNo>	Private Health Number:		

Examination Required (all testing is bulk billed) <Examination Required>	

<Echocardiogram (and choose below)>	Echocardiogram(and choose below)

<For HF Symptoms> For HF Symptoms
<For LVH or LV dysfunction> For LVH or LV dysfunction
<For Valve Disease> For Valve Disease
<Other> Other: _______________
	<Exercise Test (includes baseline ECG) (Please choose Treadmill or Exercise Bike below)>	Exercise Test
<Treadmill> Treadmill
<Exercise bike - (Stirling Only)> Exercise bike (Stirling Only)	
<Stress Echo (will include Baseline Echo appointment) (Please choose treadmill or bike below)>	Stress Echocardiogram (will include Baseline Echo appointment
<Treadmilll>Treadmill
<Exercise bike (Stirling Only)> Exercise bike (Stirling Only)	<Holter Monitor>	Holter Monitor	
<Ambulatory BP Monitor>	Ambulatory BP Monitor 
Private billing applies. Medicare rebate available only if clinical criteria are met for item 11607	<Event Monitor>	Event Monitor (3 days)	
<CT Coronary Angiogram>	CT Coronary Angiogram
(Includes specialist review to assess the patient, ensuring a CTCA is clinically appropriate and meets Medicare critera)	<ECG>	ECG	

<Please indicate if this appointment is Urgent>  Please indicate if this appointment is Urgent
<Please book patient for a Cardiology Consult if indicated by results>  Please book patient for a Cardiology Consult if indicated by results

Cardiology Consultation <Cardiology Consultation>	

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

Clinical Details	

Medical History / Medications:
<SelectedRx>

Specific Clinical Query?

<Specific Clinical Query>

*Note: Some patients may not be eligible for Medicare Rebate. Please state clinical details clearly.

Referring Doctor	

Name: <DrName>	Provider Number: <DrProviderNo>	

Signature: _____________________	
Date: <TodaysDate>	
Practice Name: <Practice>	Contact Number: <UsrPhone>	
Health Link EDI: 		

Copy of the report to: ________________________________________

Please ensure Access Cardiology receives a copy of Patient Discharge Summaries

Locations - Consulting & Testing	

Albany

102 Aberdeen Street
Albany WA 6330	Cottesloe

Shop 3 / 40 Marine Parade
Cottesloe WA 6011
(Inside Soleil Health Medical Centre)
	Joondalup

Suite 6 (Ground Floor)
Sanori House
126 Grand Boulevard
Joondalup WA 6027	
			
Mandurah

32 Minilya Parkway
(corner Lakes Road)
Greenfields WA 6210
	Murdoch

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

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

Locations - Testing Only	

Albany Hospital

Zone 2, Albany Hospital
Warden Avenue
Albany WA 6330	Midland

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

Level 1, 18 Civic Blvd
Rockingham WA 6168
(Inside Rockingham Medical & Dental Centre)	
			
Stirling

12 / 732 Karrinyup Road
Balcatta WA 6021
(Inside MedOne Medical Centre)