Suite 16, 3 Male Street, Brighton VIC 3186

CARDIAC CT
CT Coronary Angiogram & CT Calcium Score

PATIENT IDENTIFICATION

Name: <<Patient Demographics:Full Name>>	Date of Birth: <<Patient Demographics:DOB>>.

Address: <<Patient Demographics:Address>> <<Patient Demographics:City>> <<Patient Demographics:State>> <<Patient Demographics:Postcode>>	

   Telephone (M): <<Patient Demographics:Phone (Mobile)>>	(H): <<Patient Demographics:Phone (Home)>>	Medicare  No: <<Patient Demographics:Medicare Number>>

REFERRING DOCTOR INFORMATION

Name: <<Doctor:Name>>	Signature:  ..................................................................................................................

Address: <<Doctor:Address>> <<Doctor:City>> <<Doctor:State>> <<Doctor:Postcode>> 

Provider No: <<Doctor:Provider Number>> Tel: <<Doctor:Phone>> Email: <<Doctor:E-mail>>  

REQUEST FOR 	Date: <<Miscellaneous:Date (short)>>

CT Coronary Angiogram + Coronary Artery Calcium Score	CT Calcium Score (not Medicare rebateable)

CLINICAL INDICATIONS

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CTCA REFERRAL ELIGIBILITY
GP Referral (not Medicare eligible)
CT Coronary Angiogram

Specialist Referral (Medicare eligible)
Please tick appropriate option
Patient has stable or acute symptoms consistent with Coronary Ischaemia, and the patient is at low to intermediate risk of an acute coronary event
Patient has newly recognised left ventricular systolic dysfunction on unknown aetiology Patient will be undergoing Non-Coronary Cardiac Surgery
CTCA may not be suitable if your patient has:
○	Severe asthma
○	Atrial fibrillation
○	Renal impairment with eGFR <40
○	Allergy to Iodine / Contrast
Please contact Melbourne Heart Care for advice if you have any questions regarding your patient.

PATIENT INFORMATION & RISK FACTORS

Pregnant:	Yes	No	
Pacemaker:	Yes	No	

Contrast allergy	History of severe asthma (daily Ventolin use / previous ICU admission)
Previous coronary stenting or bypass surgery Thyroid – overactive
High cholesterol	Hypertension	Diabetes	Family history of CAD Smoker / ex-smoker
Renal impairment:	Yes	No
If yes, please provide latest serum creatinine: Date: .........................................................  Creatinine: .......................................................  eGFR: .......................................................

ACN 078 559 798

Melbourne Heart Care Brighton
Head Office
Suite 16, 3 Male Street
Brighton VIC 3186
Tel: 03 9592 2177
Fax: 03 9592 3177

* Please note – this map is indicative of possible public parking options close to Melbourne Heart Care only.

www.melbourneheartcare.com.au
Your doctor has recommended that you use Melbourne Heart Care.
You may choose another provider but please discuss this with your doctor first.