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	

Albany - Consulting & Testing

102 Aberdeen Street
Albany WA 6330	Albany - Testing

Zone 2, Albany Hospital
Warden Avenue
Albany WA 6330

	Joondalup

Suite 8 (Level1)
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	Midland - Testing

34 Railway Parade
Midland WA 6056
(Located inside Painwest)

Nedlands

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

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

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

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