TEST TYPE
	ECHO 	HOLTER 	EXT HOLTER  	
PATIENT DETAILS	REFERRER DETAILS	
Name: <<Patient.FullName>>
	Name: <<Provider.Name>>
	
Medicare No: <<Patient.Medicare>>
Exp: <<Patient.MedicareExpiry>>
	Provider No: <<Provider.Number>>	
Phone: <<Patient.Phone>>
	Phone: <<Practice.Phone>>	
DOB: <<Patient.DOB>>
	Copy to: <<Practice.Email>>	
Address: <<Patient.Address>>
	Signature: <<Provider.Signature>>	
Clinical notes:  <<Clinical.Notes>>                                                       Date: <<System.Date>>

	

Admin: Please complete below and email referrals to bookings@cardiodirect.com.au
	
Echo booking date:                                                     Time: 

Please make your booking with onsite reception
Heart Health Made Convenient and Affordable!                   

Unable to make an appointment with reception?
Make an appointment via QR code, online or call

P: 02 7235 9505     E: info@cardiodirect.com.au
	
Ineligibility for MBS 55126, our cardiologist will review the clinical details. The test will still be done, but it may not be billed to Medicare. In either case there will be no out-of-pocket cost to the patient. An electrocardiogram may also be deemed necessary. 	

E: info@cardiodirect.com.au
P: 02 7235 9505
W: cardiodirect.com.au