T: 02 6551 0722
E: referral.mayo@healthecare.com.au Referrals via Medical Objects preferred.

Patient Details
Name:		
Date  of Birth: 	Telephone:	

Medicare Number: 	
Ref:                                           Exp:	

Health Fund: 	
Membership  No:	

Cardiologist	 Dr Arshad Khan	 Dr Akash Dhawan 		 Dr Greg Bellamy
Cardiac Investigation 	 Urgent			 Routine
 Exercise Stress Echocardiogram	 Echocardiogram	Cardiac Consultation  Holter Monitor	 Event Monitor	ECG
Clinical Details:         

	
Medications:

	
Referring Doctor Details
Name:		
Dr Phone:	Dr Email:	

Date: 	
Provider Number:	

Address:	
Membership  No:	

Signature: 	
C.C	
Locations

 Mayo Specialist Centre Potoroo Drive
Taree NSW 2430

 Forster Private Hospital – Dolphin Suite 5A South Street
Forster NSW 2428