RACPAC Referral

Patient Name

DOB

Gender

Weight UnderweightHealthy weightOverweightObese

Height Please selectBetween 150cm - 160cmBetween 160cm - 170cmBetween 170cm to 180cmBetween 180cm to 190cm

Patient Email Address

Patient Phone

Patient Mobile Number

Address (Number & Street)

Suburb

Postcode

Medicare Number

Ref

Private Health Insurance YesNo

Emergency Contact Name

Emergency Contact Number

Inclusion Criteria

Risk Factors

Reason for Referral

Are you a GP or an Emergency Department doctor?

Surgery

Referrer Phone

Referrer Fax

Referrer Email

HealthLink Code

Provider No

Referral Date

Supervising Consultant

Have you emailed Results or ECG to reception@charlesheart.care?