St Vincent’s Heart Centre Referral
Building C, Healy Wing, 2nd Floor (C25) T: 03 9231 3000
41 Victoria Parade, Fitzroy 3065 F: 03 9231 3333
https://stvheart.com/home Email: heartcentre@svhm.org.au
Please send the referral by secure messaging or fax to St Vincent's Heart Centre who will contact the patient with an appointment time.
Patient Details Referring Doctor Details
St Vincent's UR (if known): St Vincent's UR
Name: Patient Demographics.Full Name Name: Treating Doctor.Name
Date of Birth: Patient Demographics.DOB Practice: Practice.Name
Sex: Patient Demographics.Gender
Address: Patient Demographics.Full Address Practice Address: Practice.Address
Phone (Home) Patient Demographics.Phone (Home) Phone (Work) Patient Demographics.Phone (Work) Phone: Practice.Phone > Fax: Practice.Fax
Mobile: Patient Demographics.Phone (Mobile)
Provider number: Treating Doctor.Provider Number
Medicare number: Patient Demographics.Medicare Number
Date: Miscellaneous.Date >
Pension card number: Patient Demographics.Pension Number Email: Treating Doctor.E-mail
DVA number: Patient Demographics.DVA Number
Aboriginal or Torres Strait Islander origin? (Y/N) ATSI
Please select Investigations and/or Consultation required below.
Kindly provide full clinical details and reason for referral to assist with our triage.
Cardiac Investigations * Cardiology Consultation
o Exercise stress test *
o Echocardiogram
o Exercise stress echo *
o Dobutamine stress echo *
o 12 Lead ECG
o Report
o Trace only
o 24 hour Ambulatory BP monitor
o Holter monitor
o 24 hours
o 48 hours
o 7 day event monitor + ECG
o Pacemaker / ICD check
Device company: ………………….
o Other, please state: ……………………..
* For diagnostic stress testing, patients taking beta-blocker medication such as Atenolol, Metoprolol, Carvedilol, or Bisoprolol this medication should be stopped 48 hours prior to the stress test
o General cardiology
o Chest pain and MI / PCI follow-up
o Arrhythmia clinic
o Prevention lipid management
o Cardiomyopathy & advanced heart failure
o Valvular heart disease
o Structural heart clinic
o Sports cardiology
o Hypertension
* Please provide clinical details and relevant test results
Your doctor has recommended that you use St Vincent’s Heart Centre. You may choose another provider but please discuss this with your doctor first.
Clinical details and reason for referral
Medication
Clinical Details.Medications - Current PRN
Past History
Clinical Details.History List
Investigations
Clinical Details.Result List (Selected)
Referring Doctor: Treating Doctor.Name
Signature: Date: Miscellaneous.Date
Referral Valid for: Referral Valid for
Copy To Copy To Doctors.Name
<<Click “Insert” and complete “Cardiac” section, etc.>>
Report Preference
o Electronic (Argus) o Fax o Mail o Urgent
TEST INFORMATION
Consultation Consultation is a discussion about your medical condition with a Cardiologist.
Duration: 15 to 45 minutes.
Preparation: Please bring all your medications, previous test results and other relevant correspondences.
Exercise Stress Test Exercising on a treadmill with continuous monitoring of your ECG, heart rate and blood pressure.
Duration: 30 minutes.
Preparation: Light meals only, no stimulants, no tea, coffee or cigarettes for 2 hours prior, wear comfortable
walking clothes and shoes. Please bring medication list and previous test results.
Echo An ultrasound examination of the heart (Transthoracic).
Duration: 45 minutes.
Preparation: Nil, wear comfortable clothes. Please bring any previous test results with you.
Exercise Stress Echo Combination of an echo and exercise stress test on a treadmill.
Duration: 45 minutes.
Preparation: Light meals only, no stimulants, no tea, coffee or cigarettes for 2 hours prior. Wear
comfortable walking clothes and shoes. Please bring medication list and previous test results.
Dobutamine Stress Echo Stress echo using Dobutamine medication for patients unable to exercise on a treadmill. An intravenous cannula is inserted into your hand.
Duration: 60 minutes.
Preparation: Light meals only, no stimulants, no tea, coffee or cigarettes for 2 hours prior. Wear
comfortable walking clothes and shoes. Please bring medication list and previous test results.
ECG Electrical recording of the activity of your heart, with 12 electrodes placed on your chest.
Duration: 10 minutes.
Preparation: Wear comfortable clothes.
Ambulatory BP Monitor BP monitor worn of the arm that automatically records blood pressure over a 24 hour period.
Duration: 20 minutes to attach and 5 minutes to detach.
Preparation:
Medicare rebate not available
Shower before the test (as you will not be able to shower for 24 hours). You will be asked to
return in 24 hours for monitor removal. Please bring medication list. You may wish to wear 2
piece clothing . Preferably loose fitting around the upper arms.
Holter Monitor ECG monitor that records the electrical activity of your heart over a specific time period.
Duration: 20 minutes to attach and 5 minutes to detach.
Preparation: Shower before the test (as you will not be able to shower while wearing the monitor). You will
be asked to return for monitor removal. Please bring medication list. You may wish to wear 2
piece clothing. Do not use talc or body lotion on your upper body.
7 Day Event Monitor ECG monitor worn for up to 7 days, recording the electrical activity of your heart.
Duration: 20 minutes to attach and 5 minutes to detach.
Preparation: You will be asked to return for monitor removal. Please bring medication list. You may wish to
wear 2 piece clothing. Do not use talc or body lotion on your upper body.
Pacemaker / ICD Check Pacemaker check assesses the function of your device using a magnetic and programmer.
Duration: 15 minutes.
Preparation: Nil, wear comfortable clothes. Please bring medication list and previous test results.