Cardiologists
			A/Prof Dennis Wong
Dr Yuvaraj Malaiapan
			Endocrinologist
			Dr Jessica Chang
REFERRAL REQUEST
______________________________________________________________

Date: <FormattedDate>

Re:
Name:	<PtTitle> <PtFirstName> <PtSurname>	Date of Birth:	<PtDoB>	
Address:	<PtStreet> <PtCity>, <PtPostcode>	Home Ph:	<PtPhoneH>	
		Work Ph:	<PtPhoneWk>	
		M/Care Card:	<PtMCNo>	

Referral Objectives: <Referral Objectives>

Relevant Clinical Details: <Relevant Clinical Details:>

Referring Doctor Details:
Name:	<DrFirstName> <DrSurname>	Phone:	<UsrPhone>	
Clinic:	<Practice>	Fax:	<UsrFax>	
Address:	<UsrAddress>	Provider No:	<DrProviderNo>	

Appointment to be made by:	<Appointment to be made by>	
Urgency of Appointment:	<Urgency of Appointment>	

Consultation: <CONSULTATION:>
Cardiologist Consultation	<.     Cardiologist>	Endocrinologist Consultation	<.     Endocrinologist>	
Diabetic Educator	<.     Diabetic Educator>	Dietician	<.     Dietician>	

Cardiac Investigation: <CARDIAC IVESTIGATION>
Transthoracic Echocardiography	<.     Transthoracic Echocardiography>	Exercise Stress Echocardiography	<.     Exercise Stress Echocardiography>	
24 Hour Holter Monitor	<.     24 Hour Holter Monitor>	Ambulatory BP Monitor	<.     Ambulatory BP Monitor>	
Exercise Stress ECG	<.     Exercise Stress ECG>	Cardiac CT	<.     Cardiac CT>	
12 Lead ECG	<.     12 Lead ECG>			

Investigation Results:
<Ix>
Current Medications:
<CurrentRx>

<DrName>			Signature:__________________________
<DrProviderNo>				(only needed when faxing)

_____________________________________________________________
ALL APPOINTMENTS AND CORRESPONDANCE			CLINIC HOURS
81 Blackburn Road, Glen Waverley VIC 3149			Mon - Fri 8:30am-5:00pm
Phone: 03 9802 9250		Fax: 03 9803 4364		Alternate Mon till 8:00pm
Email: admin@mcdc.net.au		Website: www.mcdc.net.au		
Argus Email: argus@mcdc.net.au