Heart of Australia
Level 1,	                               Phone: 1800 HEARTOZ (1800 432 7869)
109 Honour Avenue,                      Fax: 07 3077 7153
Chelmer, QLD 4068                        Email: reception@heartofaustralia.com
Name:	<<Patient Demographics:Full Name>>
Gender:	<<Patient Demographics:Sex>>		Date of Birth: <<Patient Demographics:DOB>>
Ethnicity:	<<ATSI Status>>  <<Patient Demographics:Ethnicity>>
Required Wheelchair Access:		<<Wheelchair access>>		Hearing Impaired: 	<<Hearing Impaired>>
Sight Impaired: 	<<Sight Impaired>>

Contact Details
Home:	<<Patient Demographics:Phone (Home)>>	Work: <<Patient Demographics:Phone (Work)>>		Mobile:	<<Patient Demographics:Phone (Mobile)>>
Preferred Contact Number:	<<Preferred contact:>>
Email:	<<Patient Demographics:E-mail>>

Address:	<<Patient Demographics:Full Address>>

Your doctor has recommended that you use Heart of Australia. You may choose another provider but please discuss this with your doctor first.
Referring Doctor Details:
Name:		<<Doctor:Name>>
Provider No:	<<Doctor:Provider Number>>
Phone:		<<Practice:Name>>
Fax:			<<Practice:Fax>>
Address:		<<Practice:Address>>

Date:		<<Miscellaneous:Date>>		Signature:		____________________________

Services Requested
Cardiology							Respiratory
[  ] Cardiology Consultation				[  ] Complex Respiratory Function Test	[  ] ECG
[  ] Transthoracic Echocardiogram			Sleep
[  ] Exercise Stress Echocardiogram		[  ] Sleep Study (In-home Sleep Apnoea Testing)
[  ] Exercise Stress Test (ECG)
[  ]24 Hour Holter Monitor				[  ] Other (Please Specity): ____________________
[  ] 24 Hour Blood Pressure Monitor							

Clinical Details
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