REQUEST FOR CARDIOLOGY DIAGNOSTIC SERVICES  			
Fax 4215 1990 or ReferralNet

For referral for Cardiologist Consultation, please use Cardiology Consultation referral template 

Referral to:
Geelong Cardiology Diagnostic Services
Level 3
Kardinia House
University Hospital Geelong
Tel: 03 4215 1955
Fax:03  4215 1990

Date of referral: Date of referral
Urgency: Urgency		Referring General Practitioner:
Treating Doctor.Name
Address: Practice.Address
HPI-O:
Ph: Practice.Phone
Fax: Practice.Fax
Provider No.: Treating Doctor.Provider Number
HPI-I:	

Consumer details:
Name: Patient Demographics.Full Name
Date of Birth:.Patient Demographics.DOB
Age:.Patient Demographics.Age
Sex: Patient Demographics.Gender
Title: Patient Demographics.Title
Pt IHI: Patient Demographics.IHI Number
ATSI:  Patient Demographics.ATSI Status
		Contact Address:
Patient Demographics.Full Name
Patient Demographics.Full Address
Tel (H): Patient Demographics.Phone (Home)
Tel (M): Patient Demographics.Phone (Mobile)
Email: Patient Demographics.E-mail
Alternative Contact: 	

Interpreter required: Interpreter required		DVA Number: Patient Demographics.DVA Number	
Preferred language is: Interpreter language		Medicare Number: Patient Demographics.Medicare Number	
Pension Card Number: Patient Demographics.Pension Number		Private Health Insurance:  Patient Demographics.Health Fund NamePatient Demographics.Health Fund Member Number	
TAC or Workcover: TAC or Workcover?		Refugee/Aslyum Seeker: Refugee/Asylum Pt?	

Request for: Request for

Clinical Information (all fields must be completed):

Weight: Weight	Height: Height	
Mobility: Mobility	Aid required: Aid required	

History/Clinical Details:
Reason for referral

Copy of report to: Copy of report to	
Date patient consented to referral:  Miscellaneous.Date	
Consent to share information:  Share information	

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