Patient Details Patient Surname * Patient Firstname * Gender * Male Female Date of Birth * Patient Email (if applicable) Patient Contact (Please enter both home and mobile numbers) * Patient Address * Medicare Number * Private Health Fund Details and Policy Number (required for TOE) Clinical Details (Please Tick Appropriate Boxes Below) Hypertension Chest Pain Asthma Bronchitis Arrythmia Stroke / TIA Chronic Dyspnea Chronic Cough Palpitatoins Diabetes COPD Pre-Op Syncopy High Cholesterol CVD SOB Appointment Details Referral Type General Physician Specialist General Physician Cardiac Services Cardiologist Consultation – General – Interventional – Arrythmia Clinic (EP) CT Coronary Angiogram (CTCA) Echocardiogram (TTE) – Initial : Suspected Heart Condition (55126) (Subject to 2 years referral restriction, If the below service has been claimed) – Repeat : Rare Real Time Echocardiogram (55134) – Frequent Repeat : [Isolated pericardial effusion, pericarditis, commenced medication for non-cardiac purposes that have cardiotoxic side effects] (55133) – Serial Echo : suspected valvular Dysfunction (55127) – Serial Repeat : Structural / Heart failure (55129) – Serial Echo : Congenital or under 17 (55132) Stress Echocardiogram – Initial Assessment (55141) Exercise Stress Echo Focused Stress Study (Subject to 2 year referral restriction, If the below service has been claimed) – Serial Repeat (55143) Repeat SE or Pharmacological (Subject to 12 months referral restriction) Dobutamine Stress Echo (Privately Billed) – Initial Assessment : Pharmacological Stress Echo (55145) (Subject to a 2 year referral restriction, cannot be claimed if stress echo was claimed within 24 months) – Follow up on failed Exercise Stress Echo : Pharmacological Stress Echo Following a Failed Exercise Stress Echo or Failed Treadmill (55146) – Repeat / Combined Test : Stress Echo or Pharmacological (55143) 24 hour ECG Holter Monitor (11716) Initial Assessment Pharmacological Stress Echo (55145) (Subject to a 2 year referral restriction, cannot be claimed if stress echo was claimed within 24 months) 24 hour BP Monitor (Privately Billed) ECG (11704) (Bulk Billed – Tracing & Report) Cardiologist Consultation – General – Interventional – Arrythmia Clinic (EP) – CT Coronary Angiogram (CTCA) Echocardiogram (TTE) – Initial : Suspected Heart Condition (55126) For echocardiogram please select indications below: – Symptoms or signs of heart failure – Ventricular hypertrophy or dysfunction – Pulmonary hypertension – Valvular disease – Pericardial disease – Aortic disease – Congenital heart disease – Cardiac tumour or thrombus – Cardiac source of embolus – Frequent Repeat : Isolated pericardial effusion, pericarditis, commenced medication for non-cardiac purposes that have cardiotoxic side effects (55133) Stress Echocardiogram – Exercise Stress Echo Focused Study (55141) Dobutamine Stress Echo (Privately Billed) * For stress echo please select indications below: – New typical or atypical angina – Known coronary disease with symptoms suggestive of ischaemia – Abnormal resting ECG ? ischaemia – Shortness of breath on exertion (SOBOE)? Cause – Indeterminate lesion on CTCA – Pre-operative with poor exercise capacity & PHx of IHD, CVA, DM on insulin, or serum Cr >170 – Assessment of valvular disease or ischaemic threshold during exercise prior to intervention – ? ischaemia in patient with impaired cognition or expressive language skills 24 hour ECG Holter Monitor (11716) Initial Assessment Pharmacological Stress Echo (55145) (Subject to a 2 year referral restriction, cannot be claimed if stress echo was claimed within 24 months) 24 hour BP Monitor (Privately Billed) ECG (11704) (Bulk Billed – Tracing & Report) Sleep & Respiratory Services Lung Function Test (15 years & older) (Combined Spirometry & Gas Transfer Factor) Sleep & Respiratory Consultation (Privately Billed) Sleep Investigation (18 years & Older) Home based Sleep study (MBS 12250) For suspected sleep apnea. If deemed necessary, a Sleep Physician appointment may be arranged, who will arrange appropriate treatment if required. Patient Category * Privately Billed W/C Bulk Billed Private Health Fund Vet/Aff TAC Preferred Location/s * Disclaimer : Not all procedures may be available at the selected location(s). Balaclava Bundoora Burwood Burwood East Caulfield South Cranbourne Dandenong Glen Waverley Kilmore Moonee Ponds Mooroolbark Pakenham Roxburgh Park St Albans Thomastown Wantirna Werribee Wheelers Hill For Sleep Studies please complete questionnaire below : The Epworth Sleepiness Scale Test How likely are you to doze off or fall asleep in the situations described, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you haven’t done some of these things recently, try to work out how they have affected you. Use the scale test on the left to choose the most appropriate number for each situation. 0 – Would never doze 1 – Slight chance of dozing 2 – Moderate chance of dozing 3 – High chance of dozing Sitting and reading 0 Watching TV 0 As a passenger in a car for an hour without a break 0 Sitting, inactive in a public place (eg. theatre or a meeting) 0 Lying down to rest in the afternoon, when circumstances permit 0 Sitting and talking to someone 0 Sitting quietly after lunch without alchohol 0 In a car, while stopped for a few minutes in traffic 0 Score Result: 0 – 7 = Normal (Bulk billing not applicable) 8 – 24 = Abnormal (Complete questionnaire below) Total * Fill in either one of the following: Stop – Bang Sleep Apnea Questionnaire for Patient : Minimum 4 Ticks to Qualify * Do you SNORE loudly (loud enough to be heard through closed doors?) Yes No Do you often feel TIRED, fatigued or sleepy during anytime? Yes No Has anyone OBSERVED you stop breathing or choking during your sleep? Yes No Do you have or are you being treated for high blood PRESSURE? Yes No BMI more than 35kg/m2? Yes No AGE older than 50 years? Yes No NECK size large (Males: 43cm+ & Females: 41cm+)? Yes No GENDER = male? Yes No OSA 50 Screening Questionnaire To Qualify for Bulk-Billing a patient must score 5 or more Waist Circumference (Male > 102cm & Female > 88cm *Waist measurement at the umbilicus level) = 3 Snoring: Has your snoring ever bothered other people? =3 Yes No Apneas: Has anyone noticed that you stop breathing during sleep? =2 Yes No Age 50+: Are you aged 50 years or over? =2 Yes No Total Score ………../10 Referring Doctor Details Doctor’s Name * Name of the Clinic * Contact Number * Address of the Clinic * Referring Doctor Provider Number * GP Email (Copy of referral will be manually forwarded to the email provided) * Date of Referral * Acknowledgement By pressing the Submit button, you acknowledge that you are a medical practitioner wishing to make a referral and you have checked to ensure all the correct information has been entered. If you are NOT a medical practitioner, please note that the named patient will not be able to claim Medicare benefits without a valid referral. 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