About Us
Our Story
Our Cardiologists
For Patients
Patient Information
Cardiac Testing
HeartRisk scan
CARDIAC PROCEDURES
Pay Online
For Doctors
Contacts
Online Referral Form
Treatment Summaries
Regional Services
Forms for Doctors
Contact Us
Our Locations
CONTACT US
08 9346 9300
AFTER HOURS
08 9382 6111
About Us
Our Story
Our Cardiologists
For Patients
Patient Information
Cardiac Testing
HeartRisk scan
CARDIAC PROCEDURES
Pay Online
For Doctors
Contacts
Online Referral Form
Treatment Summaries
Regional Services
Forms for Doctors
Contact Us
Our Locations
For Doctors
Resources
FOR DOCTORS
Contacts
Online Referral Form
Treatment Summaries
Regional Services
FOR PATIENTS
Print and Return Referral Form
Online Referral Form
"
*
" indicates required fields
Please fill in the below form, or alternatively
click here
to download our interactive PDF referral, save to your computer and send to us via fax, email or Healthlink.
Alternatively our referral templates are available within Best Practice and Medical Director, saved under Western Cardiology. If you require assistance accessing our referral templates in either Best Practice or Medical Director please contact
adminsubiaco@westerncardiology.com.au
or call
9346 9315
Patient Information
Patient Name
*
Phone
*
Address
*
Date of Birth
*
Day
Month
Year
Pensioner
Health Care Card
Veteran
Clinical Notes
Clinical Notes
Urgent Report To Be
phoned
faxed
Adult Services (Tick Services Required)
Adult Services - Test Checklist
1. ECG and REPORT
2. ECHOCARDIOGRAM
3. STRESS ECHO
4. EXERCISE TEST
5. HOLTER MONITORING (Overnight Ambulatory ECG)
6. MULTI DAY MONITOR
7. AMBULATORY BLOOD PRESSURE MONITORING
8. CORONARY CT SCAN (HeartRisk Scan)
9. PACEMAKER REVIEW
10. CARDIAC CONSULTATION
11. CHEST PAIN CLINIC
12. CV RISK ASSESSMENT
Stress Echo Indications
Angina
Ischaemia
Dyspnoea
Coronary artery disease on CT
Ambulatory BP Indications
SBP > 140
DBP > 90
Not on any antihypertensive medication
Testing Information available at
www.westerncardiology.com.au
Pediatric Services
Pediatric Services - Additional details
ECHOCARDIOGRAM (Consultation required for age under 5 yrs)
ECG and REPORT
HOLTER MONITORING (Overnight Ambulatory ECG))
Paediatric Cardiology Consult
Referring Doctor
Name
*
First
Last
Provider Phone
*
Provider Number
Practice Name & Address
*
Street Address
Practise Name
City
State / Province / Region
Postcode
Afghanistan
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Anguilla
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Austria
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Benin
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Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
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Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
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Cameroon
Canada
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Chad
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Cook Islands
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Guinea
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Guyana
Haiti
Heard Island and McDonald Islands
Holy See
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Hong Kong
Hungary
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India
Indonesia
Iran
Iraq
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Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
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Kuwait
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Maldives
Mali
Malta
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Martinique
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Mauritius
Mayotte
Mexico
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Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
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Niger
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Niue
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Panama
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Saint Kitts and Nevis
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Samoa
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Saudi Arabia
Senegal
Serbia
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Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
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Togo
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Tonga
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Tuvalu
Türkiye
US Minor Outlying Islands
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Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Signature
*
Date
*
Day
Month
Year
dd/mm/yyyy
Referring to Location:
APPLECROSS
MIDLAND
BALCATTA
JOONDALUP
MT LAWLEY
BUSSELTON
KALGOORLIE
NORTHAM
CARINE
MANDURAH
SUBIACO
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