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Fullarton 240 Glen Osmond Road Fullarton SA 5063 P 8338 0499 - F 8379 8094 Flinders Level 5 Suite 503 Flinders Private Hospital P 8172 4208 - F 8177 1589 Thank you for seeing: Patient Name: Date of Birth: Telephone (H): Address: Telephone (W): Med. No.: Clinical Details Investigations Requested Referring Doctor Details Results Phone Report: Email Report: Fax Report: Copies to Doctor Signature Date TEAR HERE 24 Hour BP Monitor Carotid Ultrasound Dobutamine Stress Echo Exercise Stress Echo Echocardiogram Exercise ECG Pacemaker Check Holter Monitor ECG LOCATIONS Consultations E [email protected] www.heartandvascular.com.au Fullarton 240 Glen Osmond Road Flinders Level 5, Suite 503, Flinders Private Hospital Southcoast District Hospital (Victor Harbor) Bay Road Goolwa 2/26 Cadell Street Riverland Regional Hospital (Berri) Maddern Street Kingston 89 Agnes Street Robe 1 Smillie Street Millicent 10 Short Street Mount Gambier Hospital Wehl Street North Naracoorte Disctrict Hospital 101 Jenkins Terrace Bordertown Memorial Hospital South Terrace Keith 26 Hender Street Mount Barker Hospital Wellington Road REQUEST FORMS MUST BE BROUGHT TO YOUR APPOINTMENT ALONG WITH YOUR MEDICARE CARD Appointment Details Appointment Time: Branch: Address: This referral form is not specific to HVI. Date: TEST WHAT IS THIS TEST? WHAT DO YOU NEED? ECG A simple recording of the electrical activity of the heart. The skin is prepared by rubbing or shaving so that recording dots can stick to the skin. Duration: 10 minutes No special preparation needed. Echocardiogram An ultrasound image of the moving heart muscle is recorded by placing a probe on the chest wall. Duration: 40 minutes No special preparation needed. Exercise Stress Echo An ultrasound image of the heart muscle is recorded before and after you exercise on a treadmill. The heart muscle image is then analysed for movement abnormalities. The skin is prepared by rubbing or shaving so that electrical impulses of the heart are also recorded during exercise. Duration: 40 minutes Avoid large meals prior to the test. Please wear comfortable shoes and bring a towel. Dobutamine Stress Echo An ultrasound image of the heart muscle is recorded before and after and during an infusion of Dobutamine. Dobutamine is a medication given into the vein that is used to speed up and increase the contraction of the heart. The heart muscle image is then analysed for movement abnormalities. The skin is prepared by rubbing or shaving so that electrical impulses of the heart are also recorded during the medical infusion. Duration: 40 minutes Avoid large meals prior to the test. Duplex Ultrasound An ultrasound image of an artery is recorded by placing a probe on the artery in the neck. Duration: 30 minutes No special preparation needed. Holter Monitor The skin is prepared by rubbing or shaving so that dots to record the heart rhythm can be applied. You will not be able to shower or bath with the monitor on. The heart rhythm is then recorded for 24 hours by a small box that can be worn on the belt or shoulder strap. The monitor will take 15 minutes to apply. Please return the monitor the next day. 24 Hr BP Monitor The BP cuff is fitted to the upper arm. You will not be able to shower or bath with the monitor on. The monitor is programmed to take blood pressure readings every 30 minutes for 24 hours. The monitor will take 15 minutes to apply. Please return the monitor the next day.
