APPOINTMENT DETAILS
Date: .......................          Time: .......................    Location:     c Brighton    c Moorabbin    c Mulgrave    c Warragul

     PATIENT IDENTIFICATION

     Name: 	  <PtFullName>					Date  of  Birth:   <PtDoB>

     Address: 	  <PtStreet>, <PtCity> <PtState> <PtPostcode>	
								
    Telephone  (M):  <PtPhoneMob>	(H):   <PtPhoneH>	Medicare  No:   <PtMCNo> <PtMCLine>

REFERRING DOCTOR INFORMATION
Name:               <DrName>                                                                   Signature: .......................................................

Address: 	 <DrStreet>, <DrCity> <DrState> <DrPostcode>

Provider No:     <DrProviderNo>	Tel:  <DrPhone>              Email:   <DrEmail>	

CLINICAL NOTES AND REASON FOR TEST:

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       ....................................................................................................................................................................................................................................................................................................................................................

REQUEST  FOR	Date of request: <TodaysDate>

c Transthoracic Echocardiogram                               Rural / Remote GP     c Valve Disease (55128)   
                                                                                                                                                            (MMM 3-7)

  c Adult (55126)                                                                                                Specialist Referrals:      c Valve Disease (55127)
  c Paediatric (<17 years in consultation with paediatric cardiologist)                                               c CCF / Structural Heart Disease (55129)
(55132)                                                                                                                                                                    c Adult Complex Congenital Heart Disease (55132)
Previous scan in last 24 months                                                                                                                    c Paediatric (55132) (<17 years) in consultation with paediatric cardiologist
c No (Medicare rebate available)
c Yes (Medicare rebate restricted to specialist referral or rural GP)
         Date of last scan: ................................... c Unknown

 c Exercise Stress Echocardiogram with 	Approved Indications:  c Typical or atypical angina	c Silent Ischaemia
           comprehensive baseline assessment (55141+55126)                                                        c Known CAD - Ischaemia	c Abn ECG                                                   
      c Exercise Stress Echocardiogram with                                                                                   c SOBOE                                                                                                                                                   c Pre-op: Risk	
           limited baseline assessment (55141)                                                                                                                 c Valve Haemodynamics
    
           Previous study within last 2 years                                                                                                                                                                 
 c No (Medicare rebate available)          c Yes (Medicare rebate restricted to specialist referral)                                                                                                                        

   c ECG Exercise Test				Age:	c  17 years or older (11729)	c Younger than 17 years (11730)

   c 12 Lead ECG (tracing and report) (11704)

  c    Holter Monitor (24 hours) (11716)		Indications:			           *Episodes at least weekly?

                                                            	c (Pre) Syncope			                  c Yes (Holter or Event)
c    Event Monitor (7 days) (11723)                                c Palpitations*                                                                          c No (Event only) 
	(>7 days) (11717)                              c Suspected    asymptomatic arrhythmia*
	                                                              c Other (describe in notes)

c   Ambulatory BP Monitor (24 hours)

  c    Pacemaker Check	              Pacemaker Model: ............................................................................................................................................	c Unknown

OUR TESTS:
c 12 LEAD ECG
A 12 lead ECG is a simple test that records the electrical activity of your heart and will take about 10 minutes to perform. Adhesive electrodes are placed on your chest, arms, and legs. You will need to remove your shirt/blouse for this test.
c ECHOCARDIOGRAM
This non-invasive test uses ultrasound waves to give us detailed images of your heart in motion, allowing us to assess your heart’s structure and function.
Allow 40-50 minutes for this test.

c EXERCISE STRESS TEST
An Exercise Stress Test measures the performance of the heart, lungs, and blood vessels. In most cases, the test is carried out to assist in making a diagnosis of coronary artery disease. The test can also be used to evaluate a patient’s capacity to undertake certain physical activities and in the planning of an appropriate training program. This test usually takes 30 minutes. You will be required to walk as long as you can on a treadmill that increases in speed and slope every three (3) minutes. Wear comfortable clothing such as a tracksuit, shorts or slacks, and a pair of comfortable walking shoes.
c STRESS ECHOCARDIOGRAM
This test combines the Exercise Stress Test with echo images of the heart to make the test more informative and accurate. You should allow 30-40 minutes for the test, avoid a heavy meal beforehand, and wear comfortable walking shoes.
c HOLTER MONITOR
A Holter Monitor is a 24 hour recording of your heart rate and rhythm. This monitor usually takes 10 minutes to apply and 5 minutes to remove the next day. Five wires are connected to adhesive electrodes on your chest, and connected to a small recorder which you will carry for 24 hours. You will need to remove your shirt/blouse for this test and it is recommended that you wear a loose fitting top. You will be given a diary to record any symptoms you may have, and you will not be able to shower until  the completion of the test.
c BLOOD PRESSURE MONITOR
A Blood Pressure Monitor records your blood pressure at regular intervals over 24 hours. This monitor usually takes 10 minutes to apply and 5 minutes to remove the next day. A blood pressure cuff is placed on your arm and connected to a small monitor that you carry with you on a shoulder strap or on your belt.
c PACEMAKER CHECK
A 15 minute procedure that wirelessly checks the pacemaker function.	
c
Melbourne Heart Care Brighton
Head Office
Suite 16, 3 Male Street
Brighton VIC 3186
Tel: 03 9592 2177
Fax: 03 9592 3177

c
Melbourne Heart Care Moorabbin
Consulting Suite C, Ground Floor Holmesglen Private Hospital
490 South Road
Moorabbin VIC 3189
Tel: 03 9592 2177
Fax: 03 9592 3177

c
Melbourne Heart Care Mulgrave
Suite 14, 529 Police Road
Mulgrave VIC 3170
Tel: 03 9795 0032
Fax: 03 9790 0644

c
Melbourne Heart Care    Warragul
2/71 Victoria Street Warragul VIC 3820
Off-street parking via Trumpy Ln Tel: 03 5622 3244
Fax: 03 5622 3277

    c
Melbourne Heart Care
Other pacing clinic locations:
   Rowville - 03 9780 8900
   Morwell - 03 5132 1289
   Wonthaggi - 03 5671 3353
   Berwick - 03 9592 2177

	

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        Your doctor has recommended that you use Melbourne Heart Care.
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