All Appointments Telephone 6169 2000
FAX 6169 2001
Cardiologist Direct Line 9480 9884
Suite 34/100 Murdoch Drive
Murdoch WA 6150	

PATIENT LAST NAME   GIVEN NAME (INCLUDING MIDDLE INITIAL)   SEX

PATIENT ADDRESS

	DATE OF BIRTH

SURGERY REFERENCE	

TELEPHONE(HOME)
	
TELEPHONE (BUSINESS)

	

CLINICAL DETAILS

URGENT	

Private Pension Veterans' Affairs	Investigations Required
A	
	
EXERCISE ECG*	

B	
	
EXERCISE ECHO*	

C	
	
DOBUTAMINE ECHO*	

D	
	
ECHO / DOPPLER	

E	
	
CAROTID ULTRASOUND	

F	
	
24HR ECG HOLTER MONITOR	

G	
	
ONE WEEK ECG EVENT RECORDER	

H	
	
ONE MONTH ECG EVENT RECORDER	

I	
	
24HR BP MONITOR	

J	
	
ECG WITH REPORT	

K	
	
CORONARY CT SCAN	

L	
	
CARDIOLOGY CONSULTATION
	
Geoffrey Lane	
	
Edmund Brice	

	
John Tan	

Keith Woollard	
	
Edmund Lee	

Andrew Liu	
	
Chris Judkins	

* Discontinue betablockers before test if clinically appropriate	

REFERRING DOCTOR (PROVIDER NUMBER, NAME, ADDRESS)

PH: 
FX: 	DOCTOR'S SIGNATURE AND REQUEST DATE