Patient Registration

Canberra Heart Clinic > Patient Registration

    Patient Registration

    Name*:

    First Name:

    Last Name:

    Address*:
    Street Address:

    Street Address Line 2:

    City:

    State/Province:

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

    Postal / Zip Code:

    Date of Birth:

    Occupation:

    Home Phone:

    Work Phone:

    Mobile Phone*:

    Private Health Insurance Fund:

    Fund Membership Number:

    Medicare Number:

    Medicare Reference Number:
    (IRN or individual reference number)

    Medicare Expiry Date:

    Health Care Card Number (HCC):

    HCC Expiry Date:

    Email Address:

    DVA Gold Card Number:

    TAC Claim Number:

    Referring Doctor:

    General Practitioner:

    Next of Kin:

    Emergency Contact Number:

    Condtions & Terms*:

    Patient Signature (Required)*:

    Cardiac Risk Factors
    NoFamily History of Coronary Heart DiseaseHigh CholesterolHigh Blood Pressure

    Cardiac Risk Factors - Smoker
    CurrentEx SmokerNever

    Cardiac Risk Factors - Diabetes:
    NoType 2- diet controlledType 2- oral medicationsType 2- insulin requiringType 1Maturity onset diabetes of the young (MODY)Impaired glucose tolerance

    Past Cardiac History:

    Medications:

    Medications Allergies:

    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)Dr Amit Michael Interventional and Structural Cardiologist (Adult)

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

    Dr Amit Michael Consulting Clinic:
    Marketplace Gungahlin, Big W Mall, First Floor, Suite 13, 30-33 Hibberson Street Gungahlin, 2912

    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:
    ConsultationStructural Heart ConsultationTransthoracic Echocardiogram24 Holter Monitor24 Hour Blood Pressure Monitor4 Day Holter Monitor7 Day Holter MonitorDevice CheckElectrocardiogram (ECG)Telehealth ConsultationStress EchocardiogramPaediatric Stress TestSignal Averaged electrocardiogram (SAECG)Transthoracic Echocardiogram With Bubble StudyTransthoracic Echocardiogram With Definity ContrastDobutamine Stress EchocardiogramStress Echocardiogram With Definity ContrastLoop Recorder ImplantationTransoesophageal EchocardiogramDirect Current CardioversionCoronary Angiography +/- Percutaneous Coronary InterventionOther

    Referral Request:
    ConsultationTransthoracic Echocardiogram24 Holter Monitor24 Hour Blood Pressure Monitor4 Day Holter Monitor7 Day Holter MonitorDevice CheckElectrocardiogram (ECG)Telehealth ConsultationStress EchocardiogramSignal Averaged electrocardiogram (SAECG)Transthoracic Echocardiogram With Bubble StudyTransthoracic Echocardiogram With Definity ContrastDobutamine Stress EchocardiogramStress Echocardiogram With Definity ContrastTransoesophageal EchocardiogramDirect Current CardioversionOther

    Referral Request:
    ConsultationTransthoracic Echocardiogram24 Holter Monitor24 Hour Blood Pressure Monitor4 Day Holter Monitor7 Day Holter MonitorDevice CheckElectrocardiogram (ECG)Telehealth ConsultationStress EchocardiogramSignal Averaged electrocardiogram (SAECG)Transthoracic Echocardiogram With Bubble StudyTransthoracic Echocardiogram With Definity ContrastDobutamine Stress EchocardiogramStress Echocardiogram With Definity ContrastLoop Recorder ImplantationTransoesophageal EchocardiogramDirect Current CardioversionOther

    Referral Request:
    ConsultationTransthoracic Echocardiogram24 Holter Monitor24 Hour Blood Pressure Monitor4 Day Holter Monitor7 Day Holter MonitorDevice CheckElectrocardiogram (ECG)Telehealth ConsultationStress EchocardiogramPaediatric Stress TestSignal Averaged electrocardiogram (SAECG)Other

    Referral Request:
    ConsultationStructural Heart ConsultationTransthoracic Echocardiogram24 Hour Blood Pressure MonitorDevice CheckElectrocardiogram (ECG)Telehealth ConsultationStress EchocardiogramSignal Averaged electrocardiogram (SAECG)Loop Recorder ImplantationCoronary Angiography +/- Percutaneous Coronary InterventionOther

    Referral Request:
    ConsultationTransthoracic Echocardiogram24 Holter Monitor24 Hour Blood Pressure Monitor4 Day Holter Monitor7 Day Holter MonitorDevice CheckElectrocardiogram (ECG)Telehealth ConsultationStress EchocardiogramSignal Averaged electrocardiogram (SAECG)Transthoracic Echocardiogram With Bubble StudyTransthoracic Echocardiogram With Definity ContrastDobutamine Stress EchocardiogramStress Echocardiogram With Definity ContrastLoop Recorder ImplantationDirect Current CardioversionCoronary Angiography +/- Percutaneous Coronary InterventionOther

    Referral Request:
    Consultation24 Holter Monitor24 Hour Blood Pressure Monitor4 Day Holter Monitor7 Day Holter MonitorElectrocardiogram (ECG)Telehealth ConsultationStress EchocardiogramSignal Averaged electrocardiogram (SAECG)Other

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

    Device Brand: (if device check has been chosen)

    MedtronicBiotronicAbbottSorin

    Condtions & Terms*:


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