Royal Hobart Hospital
Cardiology Request

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

<<Patient Demographics:Full Name>>
Medicare Number: <<Patient Demographics:Medicare Number>>
DOB: <<Patient Demographics:DOB>>  Gender: <<Patient Demographics:Sex>>
<<Patient Demographics:Full Address>>	<<Doctor:Name>>
Prov. No. <<Doctor:Provider Number>> 
<<Practice:Name>>
<<Doctor:Address>>  <<Doctor:City>>  <<Doctor:Postcode>>

Ph: <<Doctor:Phone>> Fax: <<Doctor:Fax>>	
	PH: (H) <<Patient Demographics:Phone (Home)>>  
PH: (A) <<Patient Demographics:Phone (Work)>>
Mob: <<Patient Demographics:Phone (Mobile)>> 	
Dr Signature: 

Date: <<Miscellaneous:Date (short)>>

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

Medical History:	
<<Clinical Details:History List>>	

Current Medication:	
<<Clinical Details:Medication List>>