Online Referral How it works Simply complete the form below and your referral will be submitted to Werribee Heart immediately. IMPORTANT! You must be a Registered Doctor to use this form. If you are a patient seeking a referral to use our services, please contact your GP. Step 1 of 3 33% PATIENT INFORMATIONName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Contact Number*Date of Birth* DD MM YYYY Address* Street Address Address Line 2 City State Postcode Referral Type*Werribee Mercy Hospital (Only) In-PatientWerribee Mercy Hospital (Only) OutpatientOutpatient ReferralWard*Bed* REFERRAL INFORMATIONType of Referral* Exercise Stress Echocardiogram Echocardiogram 24 Hour Holter Monitor 24 Hour ABPM (Privately Charged) Pacemaker Check Electrocardiogram (ECG) Consultation Referrers Observation/s Chest Pain Shortness of Breath Palpitations / Arrhythmia Hypertension Valvular Disease Preferred Cardiologist-Next Available-Prof Robert WhitbournProf Andrew WilsonDr Alex McLellanDr Arul BaradiDr Ben PangDr Candice ShieldsDr Cengiz CimenkayaDr Elizabeth ParatzDr Ian MatthewsDr Khoa PhanDr Tim RobertsClinical Notes & Current Medications*STRESS ECHO CLINICAL INDICATIONSSelect one of A, B or C (mandatory). Note: You must choose and least one Stress Echo Clinical Indication to refer a patient for a Stress Echocardiogram test.A) Patient displays one or more of the following symptoms of typical or atypical angina:* Constricting discomfort in the; front of the chest / neck / shoulders/ jaw / arms; or The patient’s symptoms are precipitated by physical exertion; or The patient’s symptoms are relieved by rest or glyceryl trinitrate within 5 minutes None of the above B) Patient has known coronary artery disease and has one or more symptoms suggestive of ischaemia:* Which are not adequately controlled with medical therapy; or Have evolved since the last functional study; or None of the above C) Patient qualifies if one or more of the following indications:* Assessment of myocardial ischaemia with exercise is required if a patient with congenital heart lesions has undergone surgery and reversal of ischemia is considered possible; or Assessment indicates that resting 12 lead electrocardiogram changes are consistent with coronary artery disease or ischaemia, in a patient that is without known coronary artery disease; or Coronary artery disease related lesions, of uncertain functional significance, which have previously been identified on CTCA or invasive coronary angiography; or Assessment indicates that the patient has potential non-coronary artery disease, which includes undue exertional dyspnoea of uncertain aetiology; or A pre-operative assessment of a patient with functional capacity of less than 4 metabolic equivalents confirming that surgery is intermediate to high risk, and the patient has at least one of following conditions: - ischaemic heart disease or previous myocardial infarction; or - heart failure; or - stroke or transient ischaemic attack; or - renal dysfunction (serum creatinine greater than 170umol/L or 2 mg/dL or a creatinine clearance of less than 60 mL/min); or - diabetes mellitus requiring insulin therapy Assessment before cardiac surgery or catheter-based interventions is required to - increase the cardiac output to assess the severity of aortic stenosis; or - determine whether valve regurgitation worsens with exercise and/or correlates with functional capacity; or - correlate functional capacity with the ischaemic threshold; or For patients where silent myocardial ischaemia is suspected, or due to the patient’s cognitive capacity or expressive language impairment, it is not possible to accurately assess symptom frequency based on medical history. None of the above REFERRING DOCTOR DETAILSDoctor Name* Dr.Prof.Mr.Mrs.MissMs. Prefix First Last Clinic Name*Provider Number*Upload Referral / Supporting Documents Drop files here or Signature*PhoneThis field is for validation purposes and should be left unchanged.