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,  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	

Date
Time
Location	

CONSULTATION REFERRAL
Michael Greenwood
Interventional Cardiologist
Tel: 07 5618 5508	Consult Appt - MG	
Kang-Teng Lim
Cardiologist & Electrophysiologist
Tel: 07 5618 5518	Consult Appt - KL	
Jonathan Chan
Cardiologist & Echocardiography
Tel: 07 5618 5511	Consult Appt - JC	
Vijay Kapadia
General & Interventional Cardiologist
Tel: 07 5510 2501	Consult Appt - VK	
Tony Lai
General & Interventional Cardiologist
Tel: 07 5586 5305	Consult Appt - TL	
Aaron Lin
Cardiologist & Echocardiography
Tel: 07 5586 5300	Consult Appt - AL	
Jean-Mari Mouton
Dietitian Nutritionist
Tel: 07 5531 1833	Consult Appt - JM	

TESTING REQUEST
Echocardiogram	Echocardiogram
Adult or Paed: Adult or Paed	
Transoesophageal Echocardiogram (in hospital service)	Transoesophage	
Stress Echo & Comprehensive Echo	Stress Echo	
Exercise Stress Test	Exercise Stress Test	
Holter Monitor	Holter Monitor
Holter Duration	
Holter (Wireless) Monitoring - Mobile Service	Holter (Wireless)
Wireless Duration	
24 Hour BP Monitor	24 Hour BP Monitor	
ECG	ECG	
Reason for test request	Reason for test	

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 abn	
Disk required	Disk required	
Correspondence Delivery	Correspondence del	

Clinical History

Clinical Details.Result List

Other clinical information: Other clinical

Current List of Medications

Clinical Details.Medications - Current Regular

Referring Doctor Details
Referring Doctor	Treating Doctor.Name	Provider Number	Treating Doctor.Provider Number	
Copy to	Copy to	Date	Miscellaneous.Date	

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 required (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.