Complete Doctor Referral Online

    Complete Doctor Referral Online

    Referring Doctor (Surname then First Name)*:

    First Name:

    Last Name:

    Referring Doctors Provider No:

    Referral Urgency:
    Urgent (<1 Week)Semi Urgent (<3 Week)Non Urgent (>3 Week)

    Requested Cardiologist:
    Next AvailableSpecific Cardiologist

    Specific Cardiologist: (Skip if choose 'Next Available')
    Dr Christopher Allada: Cardiologist and Interventional Cardiologist (Adult)Dr Kris Nowakowski: Cardiologist and Echocardiography Specialist (Adult)Dr Ala Mustafa: Paediatric CardiologistDr Davinder Pal Singh: General Cardiologist (Adult)

    Other Specialist / Health Care Provider:
    Dr Jaydeep Mandal: General Physician (Adult)

    Dr Ala Mustafa Consulting Clinic:
    Lidia Perin Medical Centre, 1/12 Napier Close, Deakin, 2600

    Preferred Clinic:

    Lidia Perin Medical Centre, 1/12 Napier Close, Deakin, 2600Marketplace Gungahlin, Big W Mall, First Floor, Suite 13, 30-33 Hibberson Street Gungahlin, 2912Next availiable

    Referral Request:
    ConsultationEchocardiogram24 Holter MonitorDevice CheckElectrocardiogram (ECG)Telehealth ConsultationStress Echocardiogram24 Hour Blood Pressure Monitor4 Day Holter Monitor7 Day Holter MonitorOther

    If you select other, please write down your specific referral request:

    Device Brand: (if device check has been chosen)


    Patient Name*:

    First Name:

    Last Name:

    Date of Birth*:

    Patient Phone Number:

    Street Address:

    Street Address Line 2:



    Please write down your country if you are outside of Australia:

    Postal / Zip Code:

    Patient history:

    Reason for Referral:


    How would you like to be contacted once referral made?

    PhoneEmailFaxNo need to contact me




    Referring Doctor Signature:

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