Request for:	Patient Details	
o	
Consultation	

o	
Consultation, exercise test if appropriate
(because of the inherent risk and difficulty in accurate interpretation we will not do exercise tests without consultation)	

o	
ECG	

	Name: <<Patient Demographics:Full Name>>
Address: <<Patient Demographics:Full Address>>
Medicare Number: <<Patient Demographics:Medicare Number>>
Phone: (H) <<Patient Demographics:Phone (Home)>>
Phone: (M) <<Patient Demographics:Phone (Mobile)>>
DOB: <<Patient Demographics:DOB>>	
o	Echocardiogram	Referring Doctor	
o	
Stress Echocardiogram	

o	
Holter Monitoring	

o	
Ambulatory Blood Pressure Monitoring
(There is a fee, as yet there is no Medicare rebate)	

	Name: <<Doctor:Name>>
Provider No.: <<Doctor:Provider Number>>
Practice Name: <<Practice:Name>>
Address: <<Practice:Address>>
Phone: <<Practice:Phone>>  Fax: <<Practice:Fax>>	

Clinical Details:	

Signed:	Date: <<Miscellaneous:Date>>	

HOBART HEART CENTRE PATIENT INFORMATION
Exercise Tolerance Test involves electrocardiographic (ECG) monitoring of your heart whilst walking on a treadmill. This takes about 30 minutes. Wear comfortable walking shoes and clothes that can be easily removed from the chest area (ladies will be given a gown to wear).
Electrocardiograph (ECG) records the electrical activity of your heart. It takes about 15 minutes.
Echocardiogram measures heart size and function and evaluates the heart valves. You lie on a bed and an ultrasound probe is moved over the surface of your chest. It may take up to 45 minutes. 
Stress Echocardiogram is an ultrasound imaging of the heart before and after a treadmill exercise stress test.
Holter Monitoring is the recording of each heart beat (on 3 ECG channels) for 24 hours. 
Five electrodes are placed on the chest to record the heart beats on a monitor the size of a "Walkman". Patients may not shower or bathe during the 24-hour monitoring period. Ladies: please wear skirt/slacks and high neckline top.
Ambulatory Blood Pressure Monitoring involves wearing a blood pressure cuff and monitor for 24 hours. It may be removed briefly for showering. The monitor is programmed to take your blood pressure every 30 minutes during the day and hourly at night. Please wear a loose sleeved top/shirt.