All appointments
07 3282 8333

Consultant Cardiologists

Dr Cameron Booth Dr Bennett Franjic Dr Callan Gavaghan Dr Paul Gould
Dr Andrew McCann
Dr Johannes Moolman
Dr James Robinson
Dr Michael Sawyer Dr Yash Singbal
Dr William Wang
CLINICAL DETAILS

REQUEST FORM

PATIENT DETAILS

Ipswich Cardiac Centre
33 Thorn Street
Ipswich, QLD 4305
Phone:  (07) 3282 8333

Name:  	

DOB:  	

Fax:

(07) 3282 9444

www.ipswichcardiaccentre.com.au

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