Referral Form "*" indicates required fields Referral / Request Click here to Download PDF One Heart Centre CardiologistDoctorFirst AvailableDr Rajan RehanDr Christopher YuDr Kaivan VaidyaDr Chinmay KhandkarDr Christopher KocxDr Jayant RavindranDr Jamie ChamPatient Name* First Last Date of Birth Medicare Number*Phone*Address Street Address Address Line 2 Suburb State / Province / Region Cardiac Risk Factors Hypertension Diabetes Dyslipidaemia Smoker Family History Obesity Clinical HistoryDiagnostic Request FormECHOCARDIOGRAM Ventricular dysfunction (suspected/known) Ventricular hypertrophy (suspected/known) Valvular heart disease / Murmur Pulmonary hypertension Congenital heart disease / tumour Pericardial, aortic or thromboembolic disease Cardiotoxic medication (chemotherapy) Stroke or thromboembolism Other indication (private fee) STRESS ECHOCARDIOGRAM Typical / atypical angina Chest pain or discomfort Known CAD with IHD symptoms Suspected silent ischaemia Abnormal ECG suggestive of CAD / ischaemia CTCA findings of uncertain significance Exertional dyspnoea / symptoms Pre-op assessment (IHD, CCF, CVA/TIA, CRF, DM) Other indication (private fee) Other indicationOther indicationECGExercise Stress ECG Symptoms consistent with cardiac ischaemia Cardiac disease exacerbated by exercise Suspected heritable arrhythmia Other indication (no Medicare rebate) Other indicationAmbulatory Monitoring Type 24-Hour Holter Monitor 7-Day Event Monitoring 30-Day Heart Bug Monitor Ambulatory Monitoring Syncope / presyncope Palpitations (greater than 1 week) Suspected asymptomatic arrhythmia Suspected/known TIA or stroke Surveillance post cardiac surgery Detection of AF post TIA/cryptogenic stroke 24 Hour Blood Pressure Monitoring Commenced anti-hypertensive medications (private fee) Systolic BP greater than or equal to 140mmHg Diastolic BP greater than or equal to 90mmHg Other indication (private fee) Other indicationDevice Checks (Pacemakers & Defibrillators)Pacemaker Check: Make/ModelDate of last check ICD Check: Make/ModelDate of last check REFERRING DOCTORName* First Last Provider No.*Date Email PhoneFaxAddress Street Address Address Line 2 Suburb State / Province / Region Please sign below to confirm that the information provided above is true, complete, and accurate.Full Name*Date* Email*
