Embed Size (px)
Citation preview
Referral cardiologyAppointment date and time
Patient name Date of birth
Address Phone and email
Current medications Patient history
● Hypertension
● Dyslipidaemia
● Family history
● Diabetes
● Smoker
Clinical details Referral for
● Cardiologist consultation
● Heart failure management clinic
● Rapid access chest pain clinic
● Pacemaker clinic
Investigations requested
● 1. Resting ECG
● 2. Echocardiogram
● 3. Treadmill stress echo
● 4. Dobutamine stress echo
● 5. Transoesophageal echo
● 6. Exercise stress ECG
● 7. Ambulatory BP monitor(not covered by Medicare)
● 8. Holter monitor(24 hour)
● 9. Tilt table test appointment
083
_10
/V
08/
July
19
Mail Fax Other
PromedicusArgus
Report distribution
[email protected] | genesiscare.com
Signature/dateReferring doctor Copy to
To prepare for your test, please visitgenesiscare.com/cardiology
Your doctor has recommended that you use GenesisCare for your test. Should you wish to use another provider, please discuss this with your doctor first.
Formerly:
Please print, sign and date
Cardiologists Centre locations
● Dr Joseph Amin
● Dr Garry Barron
● A/Prof Paul Calafiore
● Dr Robert Chan
● A/Prof Jaya Chandrasekhar
● Dr John Cotroneo
● A/Prof David Eccleston
● Dr Angas Hamer
● Dr Mark Horrigan
● Dr Rajika Karunadasa
● Dr Leighton Kearney
● Dr Mohammad Latif
● Dr Tina Lin
● Dr Pey Wen Lou
● Dr Ken Lu
● Dr David O’Donnell
● Dr Ali Safaa
● Dr Hamid Salehi
● A/Prof Piyush Srivastava
● Dr Matthew Swale
● Dr Wai-ee Thai
● Dr Bryan Wai
● Balwyn 481 Whitehorse RoadTel 9813 7900 | Fax 9888 6844
● Berwick Unit 2, 11 Gloucester AvenueTel 8794 2200 | Fax 8794 2210
● BundooraHealth & Wellness CentreLevel 1, Suites 8-1020 Scholar DriveTel 8467 5900 | Fax 8467 5910
● Doncaster EastSuite 1, 1008 Doncaster RoadTel 8809 6200 | Fax 8809 6210
● East Melbourne(Consulting only)Level 5,126 Wellington ParadeTel 9813 7950 | Fax 9347 6760
● HeidelbergWarringal Private HospitalSuite 1, 216 Burgundy StreetTel 9455 4800 | Fax 9458 3285
● LangwarrinSuite 235 Cranbourne-Frankston RoadTel 8769 5800 | Fax 8769 5810
● Lilydale475 Swansea RoadTel 9735 4288 | Fax 9739 7273
● Moe(Echo only)ClearView Radiology34 George StreetTel 8794 2200 | Fax 8794 2210
● MulgraveMulgrave Private HospitalChurchill Consulting SuitesBlanton DriveTel 8793 3800 | Fax 9701 2822
● North Melbourne(Echo only)Lake Imaging Specialist andResearch Centre14-20 Blackwood StreetTel 9813 7950 | Fax 9347 6760
● Pakenham(Consulting only)Lakeside Square MedicalPrecinct, Level 2, 2-9Village Way (Off Cardinia Rd)Tel 8793 3800 | Fax 9701 2822
● Parkville (Consulting only)Melbourne Private HospitalLevel 4, Suite 22, Private MedicalCentre, Royal ParadeTel 9813 7950 | Fax 9347 6760
● RingwoodSuite 22 & 23Level 2, 50 New StreetTel 9210 8300 | Fax 9210 8310
● Surrey Hills203 Union RoadTel 9813 7900 | Fax 9888 6844
● Vermont South(Consulting only)Vermont South Medical CentreLevel 3, Suite 3-5a645-647 Burwood HighwayTel 9210 8300 | Fax 9210 8310
● Whittlesea(Consulting only)Whittlesea Specialist Centre79-81 Church StreetTel 8467 5900 | Fax 8467 5910
083
_10
/V
08/
July
19
Formerly:
Appointment
Date
Time
[email protected] | genesiscare.com
