Post on 28-Jul-2020
Referral CardiologyAPPT DATE/TIME
PATIENT NAME DATE OF BIRTH
ADDRESS PHONE & EMAIL
CURRENT MEDICATIONS PATIENT HISTORY
● Hypertension
● Dyslipidaemia
● Family history
● Diabetes
● Smoker
CLINICAL DETAILS REFERRAL FOR
● Cardiologist consultation
● Heart failure management clinic
● Rapid access chest pain clinic
● Pacemaker clinic
INVESTIGATIONS REQUESTED
● 1. Resting ECG
● 2. Echocardiogram
● 3. Treadmill stress echo
● 4. Dobutamine stress echo
● 5. Transoesophageal echo
● 6. Exercise stress ECG
● 7. Ambulatory BP monitor(not covered by Medicare)
● 8. Holter monitor(24 hour)
● 9. Tilt table test appointment
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Mail Fax Other
PromedicusArgus
REPORT DISTRIBUTION
infocardiologyvic@genesiscare.com | genesiscare.com
SIGNATURE/DATEREFERRING DOCTOR COPY TO
To prepare for your test, please visitgenesiscare.com/cardiology
Your doctor has recommended that you use GenesisCare for your test. Should you wish to use another provider, please discuss this with your doctor first.
Formerly:
SIGNATURE/DATE.ÓÌÈÚÌ ×ÙÐÕÛǒ ÚÐÎÕ ɯ ËÈÛÌ
Cardiologists Centre Locations
● Dr Joseph Amin
● Dr Garry Barron
● A/Prof Paul Calafiore
● Dr Robert Chan
● A/Prof Jaya Chandrasekhar
● Dr John Cotroneo
● A/Prof David Eccleston
● Dr Angas Hamer
● Dr Mark Horrigan
● Dr Rajika Karunadasa
● Dr Leighton Kearney
● Dr Mohammad Latif
● Dr Tina Lin
● Dr Pey Wen Lou
● Dr Ken Lu
● Dr David O’Donnell
● Dr Ali Safaa
● Dr Hamid Salehi
● A/Prof Piyush Srivastava
● Dr Matthew Swale
● Dr Wai-ee Thai
● Dr Bryan Wai
● Balwyn 481 Whitehorse Road T 9813 7900 | F 9888 6844
● Berwick Unit 2, 11 Gloucester Avenue T 8794 2200 | F 8794 2210
● BundooraHealth & Wellness Centre Level 1, Suites 8-10 20 Scholar Drive T 8467 5900 | F 8467 5910
● Doncaster EastSuite 1, 1008 Doncaster Road T 8809 6200 | F 8809 6210
● East Melbourne(Consulting only) Level 5, 126 Wellington Parade T 9813 7950 | F 9347 6760
● HeidelbergWarringal Private Hospital Suite 1, 216 Burgundy Street T 9455 4800 | F 9458 3285
● LangwarrinSuite 2 35 Cranbourne-Frankston Road T 8769 5800 | F 8769 5810
● Lilydale475 Swansea Road T 9735 4288 | F 9739 7273
● MulgraveMulgrave Private Hospital Churchill Consulting Suites Blanton Drive T 8793 3800 | F 9701 2822
● Pakenham(Consulting only) Lakeside Square Medical Precinct, Level 2, 2-9 Village Way (Off Cardinia Rd) T 8793 3800 | F 9701 2822
● Parkville (Consulting only) Melbourne Private Hospital Level 4, Suite 22, Private Medical Centre, Royal Parade T 9813 7950 | F 9347 6760
● RingwoodSuite 22 & 23 Level 2, 50 New Street T 9210 8300 | F 9210 8310
● Surrey Hills 203 Union Road T 9813 7900 | F 9888 6844
● Vermont South(Consulting only) Vermont South Medical Centre Level 3, Suite 3-5a 645-647 Burwood Highway T 9210 8300 | F 9210 8310
● Whittlesea(Consulting only) Whittlesea Specialist Centre 79-81 Church Street T 8467 5900 | F 8467 5910
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Formerly:
Appointment
Date
Time
infocardiologyvic@genesiscare.com | genesiscare.com