Referrals | LifePulse Cardiology

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Referrals

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- Dr Przemek Palka
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Please Note: The forms below are to be completed by GPs and other medical specialists on behalf of their patients.

Online Form

Patient Details

First name*

Last name*

Birthday*

Day

Month

Year

Medicare Number

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Referral Request

Consulting Cardiologist (if applicable)

Dr Aleksandra Lange

Dr Przemek Palka

First Available Cardiologist

Appointment Urgency

Test Request (please select all that apply)

Ambulatory ECG / Holter Monitoring

Transthoracic Echocardiogram (TTE)

Exercise Stress Echocardiogram (ESE)

Exercise Stress Test

Cardiac CT (consultation required)

TOE Guided DC Cardioversion

Other

Specialist Clinic / Consultation

Cardio-oncology Specialised Cardiac Clinic

Heart Failure Specialised Cardiac Clinic

POTS Specialised Cardiac Clinic

Clinical Details / Reason for Referral

Referrer Details

Name

Provider Number

Practice Name

Date

Day

Month

Year

Signature

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Attach Supporting Patient Documents

PDF Download

To download a PDF copy of our referral form for return by email or fax, please click below.

Download PDF Form

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