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 Patient Demographics.Suburb Patient Demographics.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

Referring Doctor Details:
Name:	Treating Doctor.Name	Phone:	Practice.Phone	
Clinic:	Practice.Name	Fax:	Practice.Fax	
Address:	Practice.Address	Provider No:	Treating Doctor.Provider Number	

Appointment to be made by:	CUSTOMAppointment	
Urgency of Appointment:	CUSTOMUrgency	

Consultation: Consult
Cardiologist Consultation	Cardio	Endocrinologist Consultation	Endo	
Diabetic Educator	CUSTOMDE	Dietician	CUSTOMDiet	

Cardiac Investigation: Cardiac
Transthoracic Echocardiography	CUSTOMTE	Exercise Stress Echocardiography	ESE	
24 Hour Holter Monitor	CUSTOM24h	Ambulatory BP Monitor	ABPM	
Exercise Stress ECG	CUSTOMESECG	Cardiac CT	CUSTOMCCT	

12 Lead ECG	CUSTOM12LECG			

Investigation Results:
Clinical Details.Result List
Current Medications:
Clinical Details.Medications - Current PRN

Treating Doctor.Name			Signature:_______________________
Treating Doctor.Provider Number			(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