Document 6594391

Professor Hosen Kiat
Dr Anil Aggarwala
A/Prof David Rees
A/Prof Jane McCrohon
Dr Young Yu
Dr Viswanathan Venkatachalam
Dr Victar Hsieh
Dr Colin Tso
Cardiac Health Institute
Referral: External
Internal
Patient’s Name:
Address:
Please tick appropriate box
2
Consultation
Urgent Same Day Consultation
3
Stress Test
4
Echo
5
Stress Echo
6
Carotid Doppler
7
24hr Holter
8
24hr Ambulatory BP
1
(Must Phone Our Cardiologist First)
(With Pre-Test Assessment)
(With Pre-Test Assessment)
(Eastwood Only)
Nuclear Imaging (Eastwood)
Stress Sestamibi (Exercise or Persantin)
9
10
Gated Heartpool Scan
11
Myocardial Viability Scan
12
Cardiac Shunt Study
Comments:
Referring Doctor’s Name:
Signature:
Date:
CHI Eastwood
173 Shaftsbury Road
Eastwood NSW 2122
CHI Norwest
Norwest Private Hospital
& Medical Centre
Suite G4, 9 Norbrik Drive
Bella Vista NSW 2153
Ph (+61 2) 9858 9888
CHI Hurstville
75 Queens Road
Hurstville NSW 2220
CHI Macquarie
Macquarie University Clinic
Suite 202, Level 2
2 Technology Place
Macquarie University NSW 2109
| Fax (+61 2) 9858 9889 | CHI.ORG.AU | [email protected]
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CHI Eastwood
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CHI Macquarie
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