Heart Solutions Centre Referral Form

Suite 6, Level 1, Medical Centre 1, Maitland Private Hospital, 175 Chisholm Road, East Maitland

and

Suite 211, Level 2, 99 Pacific Highway, Charlestown

Email: admin@heartsolutions.com.au

Phone: 02 4086 3830 Fax: 02 4086 3831

Investigation Referral Request

To be completed by the health practitioner only. If you are a patient with a request form, please email or fax the form.

REFERRALS WILL BE ALLOCATED TO OUR EAST MAITLAND OR CHARLESTOWN ROOMS BASED ON PATIENT PREFERENCE UNLESS SPECIFIED IN THE CLINICAL DETAILS FIELD.

UrgentRoutineInpatient (Maitland Private Hospital)Inpatient (Lake Mac Private Hospital)

First Name *

Last Name *

Date of Birth *

Phone Number (including area code) *

Sex

MaleFemale

Medicare Number

Email Address

Choose one or more *

Echocardiogram (BULK BILLED)Stress Echo (East Maitland location only) (BULK BILLED)Stress ECG (East Maitland location only)Heart Bug

Clinical Details *

Referring Practitioner *

Provider Number *

Practice Name/Address *

Referrer Email Address (a copy of this form will be emailed) *

Referrer Fax Number (including area code)

Copy To:

Signature *

Draw signature|Type signatureClear

Date of Referral *