Heart Failure Clinic | Referral Form

Referring Doctor

Referring Doctors Full Name*

Referring Doctors Email

Referring Doctors Provider Number

Practice Name

Patient Details

Patient Surname*

Patient First Name*

Patient Date of Birth

Patient Phone

Reason for Referral

Tick to indicate the patient’s clinical signs and symptoms of heart failure.

MORE TYPICAL

Dyspnoea
Orthopnoea
Paroxysmal nocturnal dyspnoea
Elevated jugular venous pressure
Oedema (ankle, sacrum)
Pulmonary congestion

LESS TYPICAL

Other Comments

Included with this referral, I request a bulk-billed ECG trace with report, echocardiography, pathology tests including NT-proBNP and following patient screening, a heart failure consultation.

Other Comments

Patient Summary

Please attach a detailed patient summary to support this Heart Failure Clinic referral.

Patient Summary

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Comments

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