T  6169 2000    F  6169 2001
E  admin@wacardiology.com.au

   PATIENT DETAILS

	
 CARDIOLOGY INVESTIGATIONS (with Cardiologist report)

SURNAME:     <<Patient Demographics:Surname>>

FIRST NAME:  <<Patient Demographics:First Name>>  

DOB:                <<Patient Demographics:DOB>>

PHONE:           H  <<Patient Demographics:Phone (Home)>>  
                         M <<Patient Demographics:Phone (Mobile)>>

ADDRESS:      <<Patient Demographics:Full Address Preferred>>

MEDICARE No.  <<Patient Demographics:Medicare Number>>

PENSIONER:    <<Pensioner?>>

VETERAN:        <<Veteran?>>	
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<<Investigation - EXERCISE ECG>> EXERCISE ECG
<<Investigation - EXERCISE ECHO>>  EXERCISE ECHO & ECHO/DOPPLER
<<Investigation - DOBUTAMINE ECHO>>  DOBUTAMINE ECHO & ECHO/DOPPLER
<<Investigation - ECHO/DOPPLER>>  ECHO/DOPPLER
<<Investigation - 24HR HOLTER MONITOR>> 24HR HOLTER MONITOR
<<Investigation - 3 DAY HOLTER MONITOR>> 3 DAY HOLTER MONITOR
<<Investigation 7 DAY ECG EVENT RECORDER>> 7 DAY ECG EVENT RECORDER
<<Investigation ONE MTH ECG EVENT RECORDER>> ONE MONTH ECG EVENT RECORDER
<<Investigation - 24HR BP MONITOR>>  24HR BP MONITOR
<<Investigation - ECG WITH REPORT>>  ECG WITH REPORT
<<Investigation - CTCA with calcium score>> CTCA WITH CALCIUM SCORE
<<Investigation - CALCIUM SCORE ONLY>> CALCIUM SCORE ONLY
<<CARDIOLOGY CONSULTATION>> CARDIOLOGY CONSULTATION

CARDIOLOGIST:  <<Cardiologist>>	
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ON BETABLOCKERS? 

OFF BETABLOCKERS? 

	
	
	Please book patient for a cardiology consult if indicated by results?  		

   CLINICAL DETAILS

	
 VASCULAR INVESTIGATIONS (with Vascular Surgeon report)
	MURDOCH ONLY	
	
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<<Investigation - CAROTID ULTRASOUND>>  CAROTID ULTRASOUND
<<Investigation - AAA ULTRASOUND>> AAA ULTRASOUND
<<Investigation LOWER LIMB ARTERIAL U/SOUND>> LOWER LIMB ARTERIAL ULTRASOUND
<<Investigation LOWER LIMB (VENOUS) U/SOUND>>  LOWER LIMB VENOUS (VARICOSE VEIN) U/SOUND
<<Investigation - LOWER LIMB DVT ULTRASOUND>>  LOWER LIMB DVT ULTRASOUND
<<Investigation - RENAL DOPPLER ULTRASOUND>>  RENAL DOPPLER ULTRASOUND
<<Investigation - OVARIAN VEINS ULTRASOUND>>  OVARIAN VEINS ULTRASOUND	

	
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	REQUESTING DOCTOR	

COPY TO: <<Copy to:>>  

 URGENT RESULT <<Urgent Result ?>>    	

NAME:                           <<Doctor:Name>>
ADDRESS:                    <<Doctor:Address>>
                                       <<Doctor:City>>, <<Doctor:Postcode>>
PROVIDER NUMBER:  <<Doctor:Provider Number>>
TELEPHONE:                <<Doctor:Phone>>
FAX:                               <<Doctor:Fax>>

SIGNATURE:  ____________________________________

DATE:                            <<Miscellaneous:Date (short)>>	

Your Doctor has recommended that you use WA Cardiology for your test. 
Should you wish to use another provider, please discuss this with your Doctor first. 

Visit our website at www.wacardiology.com.au for information about your test