PATIENT:

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DATE OF BIRTH:

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ADDRESS:

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Referring Doctor: ...................................................................

Signature: ................................................................................

Date: ....................... / ................... / .........................................

Provider No: ............................................................................

Copy to: ...................................................................................

APPOINTMENT:

Date: ........ /.........../...........

Time: ............. AM / PM

LOCATION: Southport Pindara Tugun

CONSULTATION APPOINTMENTS:

Also practising coronary interventions and pacemaker implantations.

(QLD Time)

1. ECHOCARDIOGRAM

2. TRANSOESOPHAGEAL ECHO

3. STRESS ECHO

4. EXERCISE STRESS TEST

5. 24 HOUR HOLTER

6. HOLTER WITH EVENT REPORT

7. 24 HOUR BP MONITOR

8. ECG

Disk Required Yes No

ALL TESTING APPOINTMENTSPhone: 07 5531 1833

Fax: 07 5531 1834Gold Coast Private Hospital Specialist Suites 13 & 14 Ground Floor, 14 Hill Street, Southport Qld 4215

Pindara Specialist Suites Suite 2.09, Level 2, Carrara Street, Benowa Qld 4217John Flynn Medical Centre Suite 6A, Inland Dr Tugun Qld 4224

John Flynn Hospital Consulting Suites Suite 1, 79 Tamar Street Ballina NSW 2478

MICHAEL GREENWOODTel 07 5618 5508

KANG-TENG LIMTel 07 5618 5518

JONATHAN CHANTel 07 5618 5511

VIJAY KAPADIATel 07 5510 2501

TONY LAITel 07 5586 5305

THOMAS BUTLERTel 07 5586 5300

G O L D C O A S T

Please note: A formal consultation is not required in conjunction with a testing appointment. Patients with an abnormal test result will be seen for review by one of our

.detseuqer yllacfiiceps eb tsum siht revewoh ;tsigoloidracPlease tick the “consultation if abnormal” box below:

Consultation if abnormal

…caring for your heart since 1997…

PHONE: 07 55311833What do I need to do before my appointment:-

Take all medications unless otherwise advised by your Doctor.

What do I need to bring to my appointment:-

This referral and any other referrals you may require (ie. letters from your referring Doctor).

Current list of medications and dosage or alternatively you may wish to bring your medications with you.

PATIENT PREPARATION

Stress Test and Stress Echo(Diabetic Patients - please see note below)

Do not eat anything for 3 hours prior to your appointment time.

You may drink small amounts of water.

Wear comfortable clothing (a 2 piece

walking on a treadmill. Ladies will be provided with a gown.

All Other Tests

There are no special requirements.

gown.

Diabetic

If you are a diabetic please withhold your diabetic medications.

Tugun Rooms

ASHMORE RD

BEN

OWA R

D

ALLCHURCH AVE

CARRARA ST

Pindara Private

Hospital

Shops

Sir Bruce Small Park

GOLD COAST

Pindara Rooms

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GRIFFITH UNIVERSITY

CAMPUS

GOLD COASTUNIVERSITY

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GRIFFITH HEALTH CENTRE

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QUEEN STREET

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JOHNSON STREET

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HOSPITAL BOULEVARD

HOSPITAL BOULEVARD

FRAZER STREET

STANLEY LANE

FOURTH AVE.

FIFTH AVE.

HILL

STR

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KNOWLEDGE STREET

VON ITSTEIN ST

General Hospital Access Map

ALLSOPP CLOSE

Entry Point Patient drop-off

Emergency Vehicle Bay Public and staff car parking

Emergency Department

General Access

Parking

Bus Station

Tram Stop

Bus Terminus

To Pacific Motorway

To Gold Coast Highway

V2 04.16

Southport Rooms

G O L D C O A S T

To re-order, please contactour marketing staff on

Ph: 5531 1833or

Email: marketing@gchc.com.au

A copy of our Referral canalso be found on our Website at

www.gchc.com.au