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, 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)>>	

CONSULTATION REFERRAL		
Michael Greenwood
Interventional Cardiologist
Tel: 07 5618 5508	<<Consult Appointment - Michael Greenwood>>	
Kang-Teng Lim
Cardiologist & Cardiac Electrophysiologist
Tel: 07 5618 5518	<<Consult Appointment - Kang-Teng Lim>>	
Jonathan Chan
Cardiologist & Echocardiography
Tel: 07 5618 5511	<<Consult Appointment - Jonathan Chan>>	
Vijay Kapadia
Interventional Cardiologist
Tel: 07 5510 2501	<<Consult Appointment - Vijay Kapadia>>	
Tony Lai
Interventional Cardiologist
Tel: 07 5586 5305	<<Consult Appointment - Tony Lai>>	
Aaron Lin
Cardiologist
Tel: 07 5586 5300	<<Consult Appointment - Aaron Lin>>	
Wai Kah Choo
Cardiologist & Cardiac Electrophysiologist
Tel: 07 5618 5501	<<Consult Appointment - Wai Kah Choo>>	
Max Maffey
Interventional Cardiologist
Tel: 07 5618 5503	<<Consult Appointment - Max Maffey>>	
Kevin Ng
Cardiologist & Cardiac Electrophysiologist
Tel: 07 5618 5504	<<Consult Appointment - Kevin Ng>>	
Cameron Ward
Paediatric Cardiologist
Tel: 07 5531 1833	<<Consult Appointment - Cameron Ward>>	

CARDIAC INVESTIGATIONS REQUIRED		
Echocardiogram	<<Testing Appointment - Echocardiogram>>
Adult or Paed: <<Echo: Adult or Paediatric (U17 with consultation)>>	
Stress Echocardiogram & Comprehensive Echocardiogram	<<Testing Appointment - Stress- Comprehensive Echo>>	
Holter (Wireless) Monitoring	<<Holter (Wireless) Monitoring - Duration>>	
24 Hour BP Monitor	<<Testing Appointment - 24 Hour BP Monitor>>	
Stress ECG	<<Testing Appointment - Stress ECG>>	
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>>	
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
**Please do not wear any perfume or aftershave**

Stress ECG and Stress Echocardiogram 
•	Do not eat anything for 1 hour prior to your appointment time. You may drink small amounts of water.
•	Wear comfortable clothing (2 piece) and footwear

Holter Monitor (Wireless)
•	No powder or lotions on chest area
•	No showering for 6 hours after monitor is fitted
•	Wear a loose 2 piece outfit

All Other Tests
•	No specific preparation
•	Wear a loose 2 piece outfit	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.

Diabetics
If you are a diabetic you may eat as required (small meals).	

Whilst your medical practitioner has requested Gold Coast Heart Centre for your diagnostic imaging, your request may be taken to a diagnostic imaging provider of your choice. Please advise your medical practitioner if you chose another provider.