PATIENT NAME:<PtFullName>

ADDRESS:<PtAddress>

DOB:	<PtDoB>		PHONE: <PtPhoneMob>	EMAIL:	<PtEmail>	

Medicare Number: <PtMCNo>  <PtMCLine>

 MOBILE CARDIOLOGY SONOGRAPH 
   <Mobile Echocardiogram>
------------------------------------------------------------------------------------------
 24 HOUR BLOOD PRESSURE MONITOR (11607)
<24H Blood Pressure Monitor>
------------------------------------------------------------------------------------------
 12-LEAD ECG (REPORTED) (11704). NO CLAIM LIMIT:    <12 - Lead ECG and Report>
------------------------------------------------------------------------------------------
 HOLTER MONITORING (11716)     <Holter Monitor Required?>

<Indication for Holter Monitor>
------------------------------------------------------------------------------------------
EXERCISE STRESS ECHOCARDIOGRAM (55141): 
 <Exercise Stress Echo Required?>

Indication:  <Indication for ESE>
------------------------------------------------------------------------------------------
SCREENING FOR OSA  <Screening for OSA>

------------------------------------------------------------------------------------------

Clinical Details
<Clinical Details>

Medical History
<PMHAll>

Medications
<CurrentRx>

REFERRING DOCTOR DETAILS (STAMP)
<DrName>
<DrQualifications>
<DrProviderNo>

DATE:<TodaysDate>		SIGNATURE:

<Practice>

(Referrals accepted via fax, phone and medical objects. 
Bulk billing available on request from referring doctor.)
GROUND FLOOR, 105 UPTON STREET, BUNDALL, QLD, 4217

		           P 07 5531 5523     F 07 2142 5996     E: admin@zenithcardiology.com