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

Patient's Name: 	<<Patient Demographics:Full Name>>	
D.O.B: 	          <<Patient Demographics:DOB>>	
Address: 	          <<Patient Demographics:Full Address>> 	
Contact Number:	(h) <<Patient Demographics:Phone (Home)>>	(m) <<Patient Demographics:Phone (Mobile)>>	

	
Clinical Details and Reason for Request: 	
Consultation <<Consultation>>
ECG <<ECG>>
24-hour Ambulatory BP Monitor <<24-hour Ambulatory BP Monitor>>
Echocardiogram <<Echocardiogram>>
Holter Monitor <<Holter Monitor>>
Treadmill exercise test <<Treadmill exercise test>>
Treadmill exercise stress cardio <<Treadmill exercise stress cardio >>	

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:	<<Doctor:Name>>	Provider no.  <<Doctor:Provider Number>>	
Address:	                    <<Doctor:Full Address>>	

Signature:___________________________________________________  Date: <<Miscellaneous:Date>>	

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.