Request appointment

    Request Appointment Form


    Have you attended Canberra Heart Clinic in the past?*

    YesNo

    If you select "No", please go to patient registration page to fill in patient registration form which includes requested appointment section.


    Patient Name:

    Patient DOB:

    Patient Phone Number:

    Patient Email Address:

    Referring Doctor:

    Referring Doctor:

    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 Ahmad Farshid: Cardiologist and Interventional Cardiologist (Adult)Dr Ala Mustafa: Paediatric CardiologistDr Davinder Pal Singh: General Cardiologist (Adult)

    Dr Ahmad Farshid 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:

    Ticked Consultation

    Ticked Echocardiogram

    Ticked 24 Holter Monitor

    Ticked Device Check

    Ticked Electrocardiogram (ECG)

    Ticked Telehealth Consultation

    Ticked Stress Echocardiogram

    Ticked 24 Hour Blood Pressure Monitor

    Ticked 4 Day Holter Monitor

    Ticked 7 Day Holter Monitor

    Ticked Other

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

    Device Brand: (if device check has been chosen)

    MedtronicBiotronicAbbottSorin



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