Cardiology Request Form
Please ensure all patient details are accurate before submission. All divisions not selected must work through Cardiology or Internal Medicine to refer patient for investigative procedures.
Patient details
First Name
Last Name
TBH nr
Patients Birthdate
Gender
Male
Female
Patient location
Ward patient
Outpatient
Outreach patient
Radial Lounge
If outpatient date is required from echo lab please phone the lab to confirm date.
#4332
Ward
Patient infectious
Yes
No
Referring Dr.
*
Referring department
Cardiology
Cardiac Clinic
Cardio thoracic
Internal Medicine
Oncology
Anesthesiology
Appointment from clinic
Test Requesting
*
Echocardiogram
TOE
Mobile Echo
Holter ECG
Pacemaker follow-up
ECG
Effort ECG
CATHLAB
Other
PROCEDURE IN CATH LAB
Appointment CATH LAB
*
Holter ECG options
*
24 hours
48 hours
5 days
More than 5 days
TOE Preferred list
Daily TOE list
Anesthetic list
Other
Cardioversion needed
Yes
No
Dr's Phone Number
Please enter a valid phone number.
Dr's Email Address
*
example@example.com
Consultant
Prof A Pecoraro
Prof H Weich
Dr. A Mazaza
Dr P Herbst
Dr J Moses
Dr. S Sibeko
Other
Clinical Background
Indication for test
Test urgency
Urgent (Please phone if urgent #4332)
Inpatient
Outpatient
Other
Preferred Date for Echocardiography and Holter's
-
Day
-
Month
Year
Date
Medication
Submit
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