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PATIENT:
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DATE OF BIRTH:
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ADDRESS:
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CLINICAL HISTORY: .............................................
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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
HOSPITAL
GOLD COASTPRIVATE
HOSPITAL
GRIFFITH HEALTH CENTRE
TO H
OPE ISLA
ND
TO PACIFIC MOTORWAY
TO
AS
HM
OR
E
UNIVERSITY STATION
GCUH STATION
SCIENCE ROAD
ENGIN
EERIN
G DRIV
E
UN
IVER
SIT
Y D
RIVE
HO
SPI
TAL
BO
ULE
VARD
INNO
VATIO
N DRIV
E
VILLAGE WAY
EVIRD SDNALKRAP
PARKLANDS DRIVE
SMITH STREET MOTORWAY
OLS
EN A
VEN
UE
OLSEN
AVEN
UE
KU
MB
AR
I AV
ENU
E
WA
RD
OO
STR
EET
TO
SU
RFER
S P
ARA
DIS
E
OLDALLAMANDA
PRIVATE HOSPITALSITE
PACIFIC PRIVATE CLINIC
TO GOLD COAST HIGHWAY
QUEEN STREET
QUEEN STREET
NERANG STREET
NERANG STREET
TWEE
D S
TREE
T
SPENDELOVE STREET
JOHNSON STREET
BARATTA STREET
HIG
H S
TREET
HIG
H S
TREET
DA
OR
YR
REF
HOSPITAL BOULEVARD
HOSPITAL BOULEVARD
FRAZER STREET
STANLEY LANE
FOURTH AVE.
FIFTH AVE.
HILL
STR
EET
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: [email protected]
A copy of our Referral canalso be found on our Website at
www.gchc.com.au