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 Bp Premier

  Patient's Name:  <PtFullName> 	
  Address:            <PtStreet>, <PtCity>, <PtState>, <PtPostcode>	
  DOB:                 <PtDoB>       Sex: <PtSex>	
  Phone:               <PtPhoneH>	    Mobile: <PtPhoneMob>	

Please perform the following:

Consultation:         U  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.)	
  <SelectedPMH>

  Medication List
  <SelectedRx>	

  Referring Doctor: <DrName>	
  Consultant Doctor:  <DrName>
  
  Address:   <UsrAddress>	
  Phone:  <DrPhone>  Fax:  <DrFax>	
  Email: <PracEmail>         Signature:		
  Date: <TodaysDate>          Provider No: <DrProviderNo>          

  Copy to: