HEARTWISECARDIOLOGY
Heart Care with compassion and wisdom

FOR APPOINTMENTS
T: 08 6102 1655	HealthLink: hwisecrd
F: 08 6118 5522	www.heartwisecardiology.com.au
E: admin@heartwisecardiology.com.au

CARDIOLOGY REFERRAL

PATIENT INFORMATION

Patient Name: 
Date of Birth: 

Address: 
Postcode: 

Phone: 
Appointment Date/Time: 

SPECIALIST CLINICS
☐ General Cardiology Clinic
☐ Valvular & Structural Heart Disease
☐ Cardiovascular Risk Assessment
☐ Lipid Management Clinic
☐ Palpitations or Arrhythmia

INVESTIGATIONS REQUIRED
☐ Echocardiogram
☐ Stress Echo - Comprehensive (stress echo and resting echo)
☐ CT Coronary Angiogram (only rebatable if specialist referred or as part of CV risk assessment clinic)
☐ 24 Hour Holter Monitor + Resting ECG
☐ Event Monitor (7-day or 28-Day HeartBug)
☐ Ambulatory BP Monitor (not covered by Medicare)
☐ ECG and Report
☐ Transoesophageal Echo (T.O.E)

CURRENT MEDICATIONS

PATIENT HISTORY
☐ Hypertension
☐ Dyslipidaemia
☐ Family History
☐ Diabetes
☐ Smoker

CLINICAL DETAILS

BULK BILLED TESTING AND TELEHEALTH AVAILABLE

REFERRING DOCTOR INFORMATION
Consultant/Referring Dr Name: 
Signature: 

Provider Number: 
Date: 

Practice Name: 
Copy To: 

LOCATIONS: RIVERTON | PERTH CBD | NEDLANDS | JOONDALUP | GOSNELLS