Mobile Cardiac Diagnostics  |  100% Bulk-Billed via Medicare	P.  07 3067 5580     F.  07 3067 5581
E.  admin@theheartscreen.com.au
W.  www.theheartscreen.com.au	
REFERRAL FORM	

PATIENT DETAILS	
Surname:  «Surname»	First Name:  «First Name»	
Date of Birth:  «DOB»	Sex:  «Sex»	
Home No:  «Phone»	Mobile No:  «Mobile»	
Email:  «E-mail»	
Address:  «Full Address»	
Medicare No:  «Medicare Number»	

REFERRING PRACTITIONER DETAILS	
Name:  «Doctor Name»	Provider No:  «Provider Number»	
Clinic Address:  «Doctor Full Address»	
Phone:  «Doctor Phone»	Fax No:  «Doctor Fax»	
Signature:  ____________________	Date:  «Date»	

CLINICAL NOTES	

EXAMINATION REQUIRED	
Cardiology
☐  ECG
☐  24 Hour Blood Pressure Monitor
      (applicable only once in any 12-month period)
☐  Exercise Stress Test — 11729 or 11730
      (applicable once every 2 years)  + / – cardiac consultation if required
☐  Exercise Stress Echocardiogram
    ☐  Initial – 55141 (once every 2 years)
    ☐  Repeat – 55143 (once every 12 months)
          + / – cardiac consultation if required
Holter Monitoring
(applicable once in any 4-week period)
☐  24 hour
☐  7 days
Other (please specify)
_____________________________________________
_____________________________________________
_____________________________________________	Echocardiogram
INDICATIONS — INITIAL — 55126
(applicable once every 2 years) Please select indications:
☐  Abnormal heart sounds since birth, history of congenital defect, unexplained cyanosis or murmur
☐  Aortic disease
☐  Breathlessness not explained by other causes, especially if accompanied by loud heart sounds or signs of strain on ECG
☐  Cardiomyopathy (any type — dilated, restrictive, arrhythmogenic)
☐  Chest pain or tightness, family history of aortic disease, abnormal imaging suggesting enlargement of the aorta, light-headedness, vertigo
☐  Coronary artery disease (CAD)
☐  Dizziness, fainting (syncope), or unexplained neurological events that may be related to the heart, post MI, Pericarditis
☐  Embolic disease
☐  Heart tumour
☐  Hypertrophic obstructive cardiomyopathy (HOCM)
☐  Ischaemic heart disease (IHD)
☐  Known heart murmur, abnormal heart sounds, or suspicion of valve problems, chest pain, previous stroke
☐  Low blood circulation, water retention
☐  Palpitations
☐  Pericardial disease
☐  Reduced exercise tolerance, leg swelling (peripheral oedema)
☐  Shortness of breath (especially on exertion or lying flat), fatigue
☐  Sudden onset of breathlessness at night, Pulmonary hypertension (HTN), Post Chemotherapy dyspnoea
☐  Suspicion of growths or masses in the heart on imaging, or unexplained symptoms suggestive of clot, blurred vision, heart murmur
☐  Symptoms or signs of cardiac failure
☐  Symptoms/signs congenital heart disease
☐  Thrombotic disease
☐  Unexplained high blood pressure, abnormal ECG showing strain, fatigue or reduced exercise tolerance
☐  Valvular disease
☐  Ventricular hypertrophy or dysfunction
☐  Other (privately billed, no Medicare)	

Please fax completed referral to 07 3067 5581  |  Email: admin@theheartscreen.com.au  |  www.theheartscreen.com.au