Ipswich Cardiac Centre
33 Thorn Street
Ipswich, QLD 4305
Phone:	(07) 3282 8333
Fax:	(07) 3282 9444
www.ipswichcardiaccentre.com.au

All appointments 07 3282 8333

Consultant Cardiologists

Dr Cameron Booth Dr Bennett Franjic Dr Paul Gould     
Dr Vath Indrajith
Dr Andrew McCann  
Dr Johannes Moolman 
Dr James Robinson
Dr Yash Singbal
Dr William Wang

CLINICAL DETAILS

REQUEST FORM

PATIENT DETAILS

Name:  	  DOB:  	
Phone:  	

TEST DETAILS *

Clinical Consultation 
12 lead ECG 
Echocardiogram 
Exercise Stress Echo + Full Resting Echo 
Exercise Stress Echo
Exercise Stress Test 
Holter Monitor (24 hours)              7 Day Holter / Event Monitor Blood Pressure Monitor (24 hours) 
Ankle Brachial Index 
                        (additional options next page)

REFERRING DOCTOR

Name:	Date:  	

Signature:	Provider Number:  	

Address:  	

All appointments 07 3282 8333

If your request is for
Exercise Stress Test or Exercise Stress Echo
DO NOT smoke or eat 2 hours prior to your test and refrain from tea, coffee, coca cola on the day of your test. Please ensure that your referring doctor and the doctor performing the test are aware of your
medications. Wear comfortable clothes and shoes you can walk and exercise in.

Ipswich Cardiac Centre
33 Thorn Street, Ipswich, QLD 4305
Phone:  (07) 3282 8333
Fax:	(07) 3282 9444
www.ipswichcardiaccentre.com.au

Please contact us for other services including:

Coronary Angiography
Coronary Stenting & Angioplasty Cardiac Catheterisation Dobutamine Stress Echo (DSE) Transoesophageal Echo (TOE)
Electrical Cardioversion
Cardiac Electrophysiology Arrhythmia Ablation
Implantable Loop Recorders Pacemakers & Defibrillators

Corner of Thorn Street and South Street

  * Medicare payments and rebates (if available) are subject to Medicare rules