Charles Clinic Heart Care prefers to receive referrals via HealthLink SmartForms, you can find us in the Specialists & Referrals directory via the HL tab in MedicalDirector Clinical  

  Patient's Name:  <<Patient Demographics:Full Name>>	
  Address:            <<Patient Demographics:Address Line 1>>, <<Patient Demographics:City>>, <<Patient Demographics:State>>, <<Patient Demographics:Postcode>>	
  DOB:                 <<Patient Demographics:DOB>>      Sex: <<Patient Demographics:Sex at Birth>>	
  Phone:               <<Patient Demographics:Phone (Home)>>    Mobile: <<Patient Demographics:Phone (Mobile)>>	

Please perform the following:

Consultation:    Urgent			Holter Monitor	
						
		Echocardiogram			Ambulatory Blood Pressure Monitor	
						
		Exercise Stress Echo			ECG	
						
		Dobutamine Stress Echo			Pacemaker Check	
						
		Exercise Stress Test			Other (please specify) 	

  Clinical History 
(Please include previous cardiac related operative reports, medications and any special requirements e.g. reduced mobility etc.)	
  <<Clinical Details:History List>>
  
  Medication List
  <<Clinical Details:Medication List>>	

  Referring Doctor:  <<Doctor:Name>>	
  Consultant Doctor:   <<Doctor:Name>>
  
  Address:   <<Doctor:Address>>	
  Phone:  <<Doctor:Phone>> Fax:  <<Doctor:Fax>>	
  Email: <<Practice/Location:E-mail>>        Signature:		
  Date:  <<Miscellaneous:Date>>         Provider No: <<Doctor:Provider Number>>         

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