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Canberra Heart Clinic > Upload Patient Referral

    Upload Patient Referral

    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)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

    How would you like to be contacted once referral made?

    PhoneEmailFaxNo need to contact me

    Phone:

    Fax:

    Email:



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