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:  <PtSurname>	First Name:  <PtFirstName>	
Date of Birth: <PtDoB>	Sex: <PtSex>	
Home No: <PtPhoneH>	Mobile No: <PtPhoneMob>	
Email: <PtEmail>	
Address:  <PtAddress><PtStreet><PtCity><PtState>	
Medicare No: <PtMCNo>	

REFERRING PRACTITIONER DETAILS	
Name: <RefName>	Provider No:  <RefProvNo>	
Clinic Address: <RefAddress>	
Phone:  <RefPhone>	Fax No:<RefFax>	
Signature:  ____________________	Date:  <TodaysDate>	

CLINICAL NOTES	
<Comment>

EXAMINATION REQUIRED	
Cardiology
<ECG> ECG
<24 Hour Blood Pressure Monitor> 24 Hour Blood Pressure Monitor (applicable only once in any 12-month period)
<Exercise Stress Test — 11729 or 11730>Exercise Stress Test — 11729 or 11730 (applicable once every 2 years)  + / – cardiac consultation if required
<Exercise Stress Echocardiogram> Exercise Stress Echocardiogram
<Initial – 55141 (once every 2 years)> Initial – 55141 (once every 2 years)
<Repeat – 55143 (once every 12 months)> Repeat – 55143 (once every 12 months) + / – cardiac consultation if required

Holter Monitoring
(applicable once in any 4-week period)
 <24 hour> 24 hour
<7 days>  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> Abnormal heart sounds since birth, history of congenital defect, unexplained cyanosis or murmur
<Aortic disease> Aortic disease
<Breathlessness not explained by other causes, especially if accompanied by loud heart sounds or signs of strain on ECG> 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)> 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> Chest pain or tightness, family history of aortic disease, abnormal imaging suggesting enlargement of the aorta, light-headedness, vertigo
<Coronary artery disease (CAD)> Coronary artery disease (CAD)
<Dizziness, fainting (syncope), or unexplained neurological events that may be related to the heart, post MI, Pericarditis> Dizziness, fainting (syncope), or unexplained neurological events that may be related to the heart, post MI, Pericarditis
<Embolic disease> Embolic disease
<Heart tumour> Heart tumour
<Hypertrophic obstructive cardiomyopathy (HOCM)> Hypertrophic obstructive cardiomyopathy (HOCM)
<Ischaemic heart disease (IHD)> Ischaemic heart disease (IHD)
<Known heart murmur, abnormal heart sounds, or suspicion of valve problems, chest pain, previous stroke> Known heart murmur, abnormal heart sounds, or suspicion of valve problems, chest pain, previous stroke
<Low blood circulation, water retention> Low blood circulation, water retention
<Palpitations> Palpitations
<Pericardial disease> Pericardial disease
<Reduced exercise tolerance, leg swelling (peripheral oedema)> Reduced exercise tolerance, leg swelling (peripheral oedema)
<Shortness of breath (especially on exertion or lying flat), fatigue> Shortness of breath (especially on exertion or lying flat), fatigue
<Sudden onset of breathlessness at night, Pulmonary hypertension (HTN), Post Chemotherapy dyspnoea>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>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 or signs of cardiac failure
<Symptoms/signs congenital heart disease>Symptoms/signs congenital heart disease
<Thrombotic disease>Thrombotic disease
<Unexplained high blood pressure, abnormal ECG showing strain, fatigue or reduced exercise tolerance>Unexplained high blood pressure, abnormal ECG showing strain, fatigue or reduced exercise tolerance
<Valvular disease>Valvular disease
<Ventricular hypertrophy or dysfunction>Ventricular hypertrophy or dysfunction
<Other (privately billed, no Medicare)>Other (privately billed, no Medicare)	

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