PHONE:   07 3162 5310
FAX:      07 3077 7153

Email: reception@heartofaustralia.com
Web:  www.heartofaustralia.com
Mail:  Level 1, 109 Honour Ave, Chelmer QLD 4068	

PATIENT DETAILS 
Name:<PtFullName>
DOB:<PtDoB>
Phone:<PtPhoneH>   <PtPhoneMob>
Medicare: <PtMCNo>/<PtMCLine>  <PtMCExpiry>
DVA: <PtDVANo> <PtDVACard>
Sex: <PtSex>
Ethnicity: <PtEthnicity>
Address:<PtAddress>	  REFERRING DOCTOR 

Doctor:<DrName>
Provider number:<DrProviderNo>
Date:<FormattedDate>
Signature: 	

SERVICE REQUESTED
<Consultation> Consultation (specify specialty):
<ConsultType>
<StressEcho> Stress Echocardiogram
(+ / - cardiac consultation)
<TTEcho> Transthoracic Echocardiogram
<ExerciseStressTest> Exercise Stress Test 
(+ / - cardiac consultation)
<AmbulatoryECG> Overnight ECG Holter
<24-hour or 7 day>
<AmbulatoryBP> Overnight BP monitor
<ECG> ECG
<SleepStudy> Sleep Testing (In-home Sleep Apnoea Daignostic) (+ / - sleep consultation)
<SleepTherapy> Sleep Therapy (Consult +/- CPAP therapy) 
<RFT> Complex Respiratory Function Test
<Other> Other (Please Specify): 
<OtherType>
	CLINICAL DETAILS 

<ClinicalDetails>	

Your doctor has recommended that you use Heart of Australia. You may choose another provider but please discuss this with your doctor first. 	

Smoking History: <SmkStatus>
<SmkHx>

Alcohol History
<AlcHx>

Current Medications
<CurrentRx>

Allergies / Reactions
<Reactions>

Past Medical History
<PMHAll>