Hurstville: 02 9570 5666
Wetherill Park: 02 8798 7001
Wentworthville: 02 9761 9288

hurstville@cardiaccare.com.au
wetherill@cardiaccare.com.au
wentworthville@cardiaccare.com.au

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Online Referral

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Appointment Date: *

Name: *

Gender:

Medicare No. *

Referring Doctor’s Details: *

Provider No. *

Clinical details:

Investigation requested *

Consultation with 12 Lead ECG
URGENT (Same Day) Consult ** (Telephonic Advice)
Echocardiogram
Stress Echocardiogram ** (with Pre-assessment)
24hr Blood Pressure Monitor ** (charges apply)
24hr Holter Monitor/ Heart Event Monitoring
Treadmill Exercise Stress ECG ** (with Pre-assessment)
Pacemaker Check / Device Check

Doctors signature:

Appointment Time: *

DOB: *

Phone / Mobile: *

Copies to:

Address: *

Reports to be:

Posted
Faxed
Emailed

Details:

Consultation requested with *

Dr Rajesh Brahmbhatt
Dr Louis Wang
Dr Ata Rehman
Dr Inaam Ullah
Dr Shweta Sahay
Dr Xavier Brennan
Dr Ata Doost
Dr Hany Abed
FIRST AVAILABLE CARDIOLOGIST

Date *

Preferred location *

Hurstville
Suite 10, Level 2, 33 MacMahon Street Hurstville NSW 2220
Phone: 02 9570 5666
Fax: 02 9570 5644
Wetherill Park
5A Price Street Wetherill Park
NSW 2164
Phone: 02 8798 7001
Fax: 02 8798 2253
Wentworthville
20A Station Street Wentworthville
NSW 2145
Phone: 02 9761 9288
Fax: 02 9761 9290

Appointment Date: *

Appointment Time: *

Name: *

DOB: *

Gender:

Phone / Mobile: *

Medicare No. *

Copies to:

Referring Doctor’s Details: *

Address: *

Provider No. *

Reports to be:

Posted
Faxed
Emailed

Clinical details:

Details:

Investigation requested *

Consultation with 12 Lead ECG
URGENT (Same Day) Consult ** (Telephonic Advice)
Echocardiogram
Stress Echocardiogram ** (with Pre-assessment)
24hr Blood Pressure Monitor ** (charges apply)
24hr Holter Monitor/ Heart Event Monitoring
Treadmill Exercise Stress ECG ** (with Pre-assessment)
Pacemaker Check / Device Check

Consultation requested with *

Dr Rajesh Brahmbhatt
Dr Louis Wang
Dr Ata Rehman
Dr Inaam Ullah
Dr Shweta Sahay
Dr Xavier Brennan
Dr Ata Doost
Dr Hany Abed
FIRST AVAILABLE CARDIOLOGIST

Preferred location *

Hurstville
Suite 10, Level 2, 33 MacMahon Street Hurstville NSW 2220
Phone: 02 9570 5666
Fax: 02 9570 5644
Wetherill Park
5A Price Street Wetherill Park
NSW 2164
Phone: 02 8798 7001
Fax: 02 8798 2253
Wentworthville
20A Station Street Wentworthville
NSW 2145
Phone: 02 9761 9288
Fax: 02 9761 9290

Date *

Doctors signature: *

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Hurstville

02 9570 5666
02 9570 5644
hurstville@cardiaccare.com.au
Suite 10, Level 2,
33 MacMahon Street
Hurstville NSW 2220

Wetherill Park

02 8798 7001
02 8798 2253
wetherill@cardiaccare.com.au
5A Price Street,
Wetherill Park NSW 2164

Wentworthville

02 9761 9288
02 9761 9290
wentworthville@cardiaccare.com.au
20A Station Street, Wentworthville NSW 2145

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