Island Referrals Cardio Booking Form

Cardiology Service Request

Please complete this form to request an appointment with our Cardiology Team
Referring Practice/Clinic
Attending Clinician

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number

Exam Requested
Tests Requested
prevnext( X )
Colour Doppler Echocardiography
£649.20 Quantity



6-lead ECG
5-minute continuous recording

£221.64 Quantity



Holter monitoring
24h; 48h; 72h recording available. Estimate refers to 24h recording, including return special delivery shipping

£481.95 Quantity



Puppy/Kitten Heart Murmur
Investigation of a heart murmur in an asymptomatic puppy/kitten younger than 6 months

£195.00 Quantity



Total

£0.00
Terms & Conditions

I understand that this is an outpatient service only, and that there will be no consultation with my client. All diagnostic reports and clinical recommendations will be forwarded to me directly to be discussed with my client. I accept that, as the referring clinician, I will retain case responsability and that this patient will remain under my care for clinical management. I understand that the referred patient must be clinically stable and fit to travel on the day of the appointment. In the unlikely event of sedation being required, this will be charged additionally.
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Cardiology Service Request