All Appointments Telephone 6169 2000
FAX 6169 2001
bookings@wacardiology.com.au	

PATIENT LAST NAME   GIVEN NAME (INCLUDING MIDDLE INITIAL)

PATIENT ADDRESS

	DATE OF BIRTH

MEDICARE #	

TELEPHONE(HOME)
	
TELEPHONE (BUSINESS)

	

CLINICAL DETAILS

URGENT	

Private Pension Veterans' Affairs	CARDIOLOGY INVESTIGATIONS

1	
	
EXERCISE ECG*	

2	
	
EXERCISE ECHO & ECHO/DOPPLER*	

3	
	
DOBUTAMINE ECHO & ECHO/DOPPLER*	

4	
	
ECHO/DOPPLER	

5	
	
24HR HOLTER MONITOR	

6	
	
3 DAY HOLTER MONITOR	

7	
	
1 MONTH ECG EVENT RECORDER	

8	
	
24HR BP MONITOR	

9	
	
ECG WITH REPORT	

10	
	
CTCA WITH CALCIUM SCORE	

11	
	
CALCIUM SCORE ONLY	

* Discontinue betablockers before test if clinically appropriate

VASCULAR INVESTIGATIONS

14	
	
CAROTID ULTRASOUND	

15	
	
AAA ULTRASOUND	

16	
	
LOWER LIMB ARTERIAL ULTRASOUND	

17	
	
LOWER LIMB VENOUS ULTRASOUND   LEFT   RIGHT	

18	
	
LOWER LIMB DVT ULTRASOUND        LEFT   RIGHT	

19	
	
RENAL DOPPLER ULTRASOUND	

20	
	
OVARIAN VEINS ULTRASOUND	

REFERRING DOCTOR (PROVIDER NUMBER, NAME, ADDRESS)

PH: 
FX: 	DOCTOR'S SIGNATURE AND REQUEST DATE

PROVIDER #