Royal Hobart Hospital
Cardiology Request

Fax: 6234 2852   Result enquiries  Ph: 6166 8620
	Patient Details	Requesting GP	
	Patient ID No: 

<PtName>
Medicare Number: <PtMCNo>
DOB: <PtDoB>  Gender: <PtSex>
<PtAddress>	<DrName>
Prov. No. <DrProviderNo> 
<Practice>
<DrStreet>  <DrCity>  <DrPostcode>

Ph: <DrPhone> Fax: <DrFax>	
	PH: (H) <PtPhoneH>  
PH: (A) <PtPhoneWk>
Mob: <PtPhoneMob> 	
Dr Signature: 

Date: <TodaysDate>

Request for:		Echocardiography		E.C.G	
		Exercise test		Ambulatory BP  (Outpatient)	
		Holter Monitor		Tilt Table	
		Pacemaker/Defib Test			
    
Allergies:	
<Reactions>	

Medical History:	
<SelectedPMH>	

Current Medication:	
<SelectedRx>