Coastal Heart & Vascular
Complete Cardiovascular Care	
www.coastalhearts.com.au
reception@coastalhearts.com.au

	Gold Coast
Suite 9, Ground Floor
Gold Coast Private Hospital
14 Hill Street, SOUTHPORT
PH  1300 912 345   
FAX  07 5532 9890

Appointment Category		Assoc. Professor Ross Sharpe 
Cardiac & Endovascular Interventionalist	
	Urgent (this week)
		Next available 
(usually 1-2 weeks, depending on location)	
	Annual/ progress review date ______________		Consult if tests abnormal	
Please attach latest pathology results
To Doctor	<<To Doctor>>	<<Doctor - Other>>	
Patient Name:	<<Patient Demographics:Full Name>>	Sex:	<<Patient Demographics:Sex>>	
Address:	<<Patient Demographics:Address>> <<Patient Demographics:City>> <<Patient Demographics:State>> <<Patient Demographics:Postcode>>	
DOB:	<<Patient Demographics:DOB>>	Medicare Number:	<<Patient Demographics:Medicare Number>>	
Telephone:	<<Patient Demographics:Phone (Home)>>	<<Patient Demographics:Phone (Work)>>	<<Patient Demographics:Phone (Mobile)>>	
	(Home)	(Work)	(Mobile)	
Period of Referral:	<<Period of Referral?>>	

Clinical Details (Please include medications and any special requirements, eg reduced mobility etc)	
<<Clinical Details (include special requirements)?>>

Allergies:
<<Clinical Details:Allergies>>	
Medications:
<<Clinical Details:Medication List>>

FOR THIS REFERRAL TO BE VALID THE FOLLOWING MUST BE COMPLETED:
Referring Doctor:
Provider Number:
Date:
Address:

Signature:
	<<Doctor:Name>>
<<Doctor:Provider Number>>
<<Miscellaneous:Date>>
<<Doctor:Address>> <<Doctor:City>> <<Doctor:State>> <<Doctor:Postcode>>

	Consultation
 Echocardiogram      Stress Echocardiogram
 Exercise Stress Test
 Transcranial Doppler (PFO screening)
 Carotid and vertebral duplex
 Aorta & Iliac artery duplex
 Renal artery duplex
 Mesenteric artery duplex
  lower extremity arterial duplex
  left  right  bilateral
  Consult if tests abnormal
Other ___________________________

<<Summary:Investigation Results (Selected)>>

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