Gold Coast Heart Centre

Phone: 07 5531 1833
Fax: 07 5531 1834

Send via Medical Objects to:
Gold Coast Heart Centre
XG421500065	GC Private Hospital, Suites 13 & 14 Ground Floor, 14 Hill Street, Southport QLD 4215
Pindara Specialist Suites, Suite 2.09, Level 2, 29 Carrara Street, Benowa QLD 4217
John Flynn Medical Centre, Suite 6, 6th Floor, 42 Inland Drive, Tugun QLD 4224
GCHC Hope Island, Healthscope Specialist Suites, Level 1, Suite 5, Harbour Point, 8 Santa Barbara Road, Hope Island QLD 4212	

Patient Name	RE: <<Patient Demographics:Full Name>>	
Date of Birth	DOB: <<Patient Demographics:DOB>>	
Phone Number	Home: <<Patient Demographics:Phone (Home)>>
Mobile: <<Patient Demographics:Phone (Mobile)>>	

Appointment Details (if known)

Date
Time (Qld time)
Location	

<<Appointment Details (if known) - Date>>
<<Appointment Details (if known) - Time (Qld time)>>
<<Appointment Details (if known) - Location>>	

CONSULTATION REFERRAL		
Michael Greenwood
Inteventional Cardiologist
Tel: 07 5618 5508	<<Consult Appointment - Michael Greenwood>>	
Kang-Teng Lim
Cardiologist & Electrophysiologist
Tel: 07 5618 5518	<<Consult Appointment - Kang-Teng Lim>>	
Jonathan Chan
Cardiologist & Echocardiography
Tel: 07 5618 5511	<<Consult Appointment - Jonathan Chan>>	
Vijay Kapadia
General & Interventional Cardiologist
Tel: 07 5510 2501	<<Consult Appointment - Vijay Kapadia>>	
Tony Lai
General & Interventional Cardiologist
Tel: 07 5586 5305	<<Consult Appointment - Tony Lai>>	
Ben Auld
Fetal & Paediatric Cardiologist
Tel: 07 5531 1833	<<Consult Appointment - Ben Auld>>	
Aaron Lin
Cardiologist & Echocardiography
Tel: 07 5586 5300	<<Consult Appointment - Aaron Lin>>	
Jean-Mari Mouton
Dietitian Nutritionist
Tel: 07 5531 1833	<<Consult Appointment - Jean-Mari Mouton>>	

TESTING REQUEST		
Echocardiogram	<<Testing Appointment - Echocardiogram>>
Adult or Paed: <<Echo: Adult or Paediatric (U16 with consultation)>>	
Transoesophageal Echo (in hospital service)	<<Testing Appointment - Transoesophageal Echo>>	
Stress Echo	<<Testing Appointment - Stress Echo>>	
Exercise Stress Test	<<Testing Appointment - Exercise Stress Test>>	
Holter Monitor	<<Testing Appointment - Holter Monitor>>
<<Holter Monitor - Duration>>	
Holter (Wireless) Monitoring - Mobile Service	<<Testing Appt - Holter (Wireless) Monitoring - Mobile>>
<<Holter (Wireless) Monitoring - Mobile - Duration>>	
24 Hour BP Monitor	<<Testing Appointment - 24 Hour BP Monitor>>	
ECG	<<Testing Appointment - ECG>>	
Reason for test request	<<Reason for test request>>	

Please note: A formal consultation is not required in conjunction with a testing appointment. Patients with an abnormal test result will be seen for review by one of our cardiologists; however this must be specifically requested. Please indicate "consultation if abnormal" below.

Consultation if abnormal	<<Consultation if abnormal>>	
Disk required	<<Disk required>>	
Correspondence Delivery	<<Correspondence Delivery>>	

Clinical History

<<Clinical Details:History List>>

<<Operation:CoMorbidities>>

<<Operation:Previous Procedures>>

Other clinical information: <<Other clinical information>>

Current List of Medications

<<Clinical Details:Medication List>>

Referring Doctor Details
Referring Doctor	<<Doctor:Name>>	Provider Number	<<Doctor:Provider Number>>	
Copy to	<<Referring Doctor Details - Copy to>>	Date	<<Miscellaneous:Date (short)>>	

Signature

Patient Preparation
Stress Test and Stress Echo (Diabetic Patients - please see note below)
•	Do not eat anything for 1 hour prior to your appointment time. You may drink small amounts of water.
•	Wear comfortable clothing (preferably a 2 piece outfit) and footwear as you will be walking on a treadmill. Ladies will be provided with a gown.

All Other Tests
•	There are no special requirements.
•	Please wear a loose fitting 2 piece outfit. Ladies will be provided with a gown.

Diabetics
•	If you are a diabetic you may eat as required (small meals).	What do I need to do before my appointment
•	Take all medications unless otherwise advised by your doctor.

What do I need to bring to my appointment
•	This referral and any other referrals you may require (ie letters from your referring Doctor).
•	Current list of medications and dosage.
•	Previous x-rays or scans if applicable.

NOTE: Your doctor has recommended that you use the Gold Coast Heart Centre. You may choose another provider but please discuss this with your doctor first.