Patient Name:  <PtFullName>     DOB: <PtDoB>    Sex: <PtSex>     
Address:  <PtAddress>
Home Phone: <PtPhoneH>    Wk Phone: <PtPhoneWk> 
Medicare Number: <PtMCNo>    DVA Number: <PtDVANo> 	
*REQUIRED FIELDS   
*Mobile: <PtPhoneMob>    
*Email: <PtEmail> 

EXAMINATION REQUEST	

<Type>
	
<Examination Request Details>	
Referring Doctor: <DrName> 
Provider Number: <DrProviderNo>
<Practice>, 
<UsrAddress>
Phone: <UsrPhone>   Fax: <UsrFax>

Referral Date: <TodaysDate>

Do not send reports to My Health Record q 	Instructions for referring GP:

On behalf of your patient, please send a copy of this referral to:

admin@cardiologygroup.com.au

Your patient will be contacted to arrange the requested appointment(s).
* Patient email &/or mobile essential