Request Form                  	Suite 1, 25 Argyle St, Hobart, Tasmania, 7000
P: 03 6222 4200 | F: 03 6222 4222 | Healthlink ID: hcardiol	

Patient's Name: 	<PtFullName>	
D.O.B: 	          <PtDoB>		
Address: 	          <PtAddress>  	
Contact Number:	(h) <PtPhoneH> 	(m) <PtPhoneMob>	

	
Clinical Details and Reason for Request: 	
<Clinical Details and Reason for Request>

Please note that stress echo is more specific and sensitive, and is escpecially preferable for females, who have a higher rate of false positives in ordinary exercise ECG tests. Patients must be able to walk on a treadmill when requesting this form of testing.

	
Requesting Doctor:	<DrName>		Provider no.  <DrProviderNo>	
Address:	                    <DrAddress>	

Signature:___________________________________________________  Date: <TodaysDate>	

Your Doctor has recommended that you use Hobart Cardiology and Medical Specialists for your testing.
You may choose another provider, but please discuss this with your doctor first.