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

Date: <<Miscellaneous:Date>>

Re:
Name:	<<Patient Demographics:Title>> <<Patient Demographics:First Name>> <<Patient Demographics:Surname>>	Date of Birth:	<<Patient Demographics:DOB>>	
Address:	<<Patient Demographics:Address Preferred Line 1>> <<Patient Demographics:Address Preferred City>>, <<Patient Demographics:Address Preferred Postcode>>	Home Ph:	<<Patient Demographics:Phone (Home)>>	
		Work Ph:	<<Patient Demographics:Phone (Work)>>	
		M/Care Card:	<<Patient Demographics:Medicare Number>>	

Referral Objectives: <<Referral Objectives>>

Relevant Clinical Details: <<Relevant Clinical Details>>

Referring Doctor Details:
Name:	<<Doctor:Name>>	Phone:	<<Practice:Phone>>	
Clinic:	<<Practice:Name>>	Fax:	<<Practice:Fax>>	
Address:	<<Practice:Address>>	Provider No:	<<Doctor:Provider Number>>	

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 INVESTIGATION>>
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		
Email: admin@mcdc.net.au		Website: www.mcdc.net.au		
Argus Email: argus@mcdc.net.au