Doctors Patient Referral Form Patient Details First Name Last Name Date of Birth Phone Number Address Medicare Number Clinical Details Referral for Cardiology Consultation Echocardiogram Holter Monitor ECG and Report CT Coronary Angiogram (includes specialist review for patient assessment and preparation) Presenting Complaint Chest pain Palpitations, presyncope or syncope Dyspnoea or heart failure symptoms Cardiac risk assessment Known cardiac condition for review Other (please provide details) Clinical Details Past Medical History and Medications Referring Doctor Referring Doctor Name Treating Consultant Name Practice Name Are you the patient's regular GP? Yes No Contact Number Referring Doctor Mobile Provider Number HeathLink EDI Please upload ECG and/or relevant documentation Message or Comment The patient or guardian consents (expressly or impliedly) to the collection of information, the information is reasonably necessary for their care, and they are aware of their rights under the Privacy Act Submit
