Referral

medical and nurse looking for something on a digital tablet at the hospital

Phone: 0738 615 522

Between the hours of 8.00am to 5.00pm Monday to Friday

Email: reception@qldcardiology.com.au

Referral Forms: Open and download the PDF Form or fill in the online referral form below.

Please note the patient will need to bring a signed referral to their appointment.

Print then Fax to (07) 3861 5622.

Online Request Form

Reason for Referral:
ConsultationInvestigationConsultation & Investigation

Patient Details:

Title

First name

Surname

Date of Birth

Address

Suburb

State

Postcode

Mobile phone

Home number

Test/s Required:
ECG and ReportHolter MonitorExercise Stress TestEchocardiographyStress EchoTransoesophageal24 Hr Ambulatory BP MonitoringHead Up Tilt TestPacemaker Test

Clinical Details:
HypertensionSmokerFamily history of CADDiabetesDyslipidemiaOther (specify below)

Additional details:

Referring Doctor:

First name

Surname

Provider number

Practice Name

Phone number

Referral date

Note: The patient will need to bring a signed request form to their appointment. Alternatively, this can be faxed (0738 615 522) or sent via Medical Objects