Referral	
PATIENT DETAILS	REFERRER DETAILS	
Name: <<Patient Demographics:Full Name>>
DOB: <<Patient Demographics:DOB>>
Address: <<Patient Demographics:Address>> <<Patient Demographics:Address Preferred City>> <<Patient Demographics:Address Preferred Postcode>>
Phone: <<Patient Demographics:Phone (Home)>>  Mobile: <<Patient Demographics:Phone (Mobile)>>
Medicare No: <<Patient Demographics:Medicare Number>>	Doctor: <<Doctor:Name>>
Provider Number: <<Doctor:Provider Number>>
Practice Name: <<Practice:Name>>
Address: <<Practice:Address>>
Phone No: <<Practice:Phone>>
Referral Date: <<Miscellaneous:Date>>	

REQUEST DETAILS	
	
	55126: ECHO
 Symptoms or signs of heart failure including shortness of breath, fatigue, peripheral edema
 Suspected or known ventricular hypertrophy or dysfunction
 Pulmonary hypertension
 Valvular disease
 Pericardial disease
 Aortic disease
 Symptoms or signs of congenital heart disease
 Cardiac tumour or thrombus
 Cardiac source of embolus
 Family history of cardiomyopathy or sudden cardiac death of immediate relative
 Prior to commencement of specific drugs which require cardiac monitoring 
 OTHER INDICATION - NO MBS REBATE	
	11716: 24 HOUR HOLTER MONITOR
 Unexplained syncope or presyncope
 Palpitations > 1 episode per week
 Suspected arrhythmia > 1 episode per week 
 Surveillance post cardiac surgery known to cause arrhythmia
 OTHER INDICATION - NO MBS REBATE	
	11707: ECG - 12 LEAD
 Syncope or presyncope
 Palpitations > 1 episode per week
 Suspected arrhythmia > 1 episode per week 
 Surveillance post cardiac surgery known to cause arrhythmia
 OTHER INDICATION - NO MBS REBATE	
	
Clinical notes:	<<Clinical Notes?>>