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1300 R HEART (1300 7 43278)
CARDIOLOGY CENTRE
admin@rotarhearthealth.com.au
Need Referral Pads?
Booking Enquiry
Service
ECG
Holter Monitor
MyPatch Holter Monitor
Blood Pressure Monitor
Echocardiogram (ECHO)
Exercise Stress Echo
Stress ECG
Pacemaker Check
Cardiac Consultation
Paediatric Cardiology Services
About us
For patients
About your appointment
Book appointment
Evening Clinic
Cardiac investigations for CASA
Patient Education
Patient satisfaction survey
CPR course
Privacy policy
For doctors
General Information
Download PDF referral form
Referral process
MBS Rules Information
Syncope Clinic
Stroke/TIA cardiac evaluation
Paediatric Murmur Clinic
Education specialist program
Evening clinic
Cardiac investigations for CASA
News
CASA Compliance
Cardiac investigations for CASA
Contact us
Menu
Service
ECG
Holter Monitor
MyPatch Holter Monitor
Blood Pressure Monitor
Echocardiogram (ECHO)
Exercise Stress Echo
Stress ECG
Pacemaker Check
Cardiac Consultation
Paediatric Cardiology Services
About us
For patients
About your appointment
Book appointment
Evening Clinic
Cardiac investigations for CASA
Patient Education
Patient satisfaction survey
CPR course
Privacy policy
For doctors
General Information
Download PDF referral form
Referral process
MBS Rules Information
Syncope Clinic
Stroke/TIA cardiac evaluation
Paediatric Murmur Clinic
Education specialist program
Evening clinic
Cardiac investigations for CASA
News
CASA Compliance
Cardiac investigations for CASA
Contact us
appotment
1300 R HEART (1300 7 43278)
admin@rotarhearthealth.com.au
Need Referral Pads?
Booking Enquiry
Service
ECG
Holter Monitor
MyPatch Holter Monitor
Blood Pressure Monitor
Echocardiogram (ECHO)
Exercise Stress Echo
Stress ECG
Pacemaker Check
Cardiac Consultation
Paediatric Cardiology Services
About us
For patients
About your appointment
Book appointment
Evening Clinic
Cardiac investigations for CASA
Patient Education
Patient satisfaction survey
CPR course
Privacy policy
For doctors
General Information
Download PDF referral form
Referral process
MBS Rules Information
Syncope Clinic
Stroke/TIA cardiac evaluation
Paediatric Murmur Clinic
Education specialist program
Evening clinic
Cardiac investigations for CASA
News
CASA Compliance
Cardiac investigations for CASA
Contact us
Menu
Service
ECG
Holter Monitor
MyPatch Holter Monitor
Blood Pressure Monitor
Echocardiogram (ECHO)
Exercise Stress Echo
Stress ECG
Pacemaker Check
Cardiac Consultation
Paediatric Cardiology Services
About us
For patients
About your appointment
Book appointment
Evening Clinic
Cardiac investigations for CASA
Patient Education
Patient satisfaction survey
CPR course
Privacy policy
For doctors
General Information
Download PDF referral form
Referral process
MBS Rules Information
Syncope Clinic
Stroke/TIA cardiac evaluation
Paediatric Murmur Clinic
Education specialist program
Evening clinic
Cardiac investigations for CASA
News
CASA Compliance
Cardiac investigations for CASA
Contact us
CPR course
need referral pads?
Clinic Name*
Address*
Contact Phone*
Email*
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Pad Type*
Standard (A4)
Brighton Only (A5)
Frankston Only (A5)
Castlemaine Only (A5)
Additional Order Details
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BOOK YOUR APPOINTMENT
First Name*
Last Name*
DOB*
Address
Mobile*
Medicare Number
Referring Doctor*
Type of booking*
Choose type of booking
ECG
Blood pressure monitor
Blood pressure @ home
Holter monitor
Holter @ home
Echocardiogram
Are you a new patient?
Yes
No
Send
New patient registration form
Title
--- Choose ---
MR
MRS
MISS
MS
Date of birth *
Given Name *
Surname *
Residential Address *
Mobile *
Home Phone
Work
Medicare № *
Reference № *
Expiry Date
Emergency Contact person *
Relationship *
Phone *
Address
Next of Kin
Relationship
Phone
Address
Referring Dr *
Name of your usual Dr (GP) *
Consent to release medical documents
Have you had any recent admission to Hospital relating to your heart?
--- Choose ---
YES
NO
Have you seen a Cardiologist in the past? *
--- Choose ---
YES
NO
How did you hear about us? *
Have you had any recent Cardiac related tests
ECHOCARDIOGRAM (ultrasound of your heart)
HOLTER MONITOR
ECG
24 HOUR BLOOD PRESSURE MONITOR
CT SCAN (ie: CT Chest / CT Coronary Angiogram)
CARDIAC MRI (MRI of your heart)
STRESS ECHOCARDIOGRAM (MIBI stress test)
OTHER
No
Have you had any recent Cardiac related Procedures
CORONARY ANGIOGRAM
DIRECT CURRENT REVERSION (DCR)
TRANSESOPHAGEAL ECHOCARDIOGRAM
PACEMAKER or DEFIBRILATOR INSERTION
BRAND OF PACEMAKER/DEFIBRILATOR
No
If you indicated any from the above please state: test, clinic/hospital and date
If you indicated any from the above please state: test, clinic/hospital and date
Medications List Do you take the following Medication?
Aspirin
Cartia
Plavix
Clopidogrel
Warfarin
Other blood thinning agent
No
Do you take any other Medication Regularty
Are you Allergic to anything?
Yes
No
Medication:
Allergy
Reason for taking: (e.g. Blood Pressure):
Type of Reaction
I consent to the release / access by the Rotar Heart Health staff of my medical record to / of any health service provider that requires the information for the purpose of treatment or audit of my current, past or any future conditions.
Send
