Phone 3139 4010    Fax 31394577	
Ground Floor, Private Practice Clinic, The Prince Charles Hospital
627 Rode Road, Chermside, QLD, 4032	

PATIENT DETAILS
Name	<<Patient Demographics:First Name>> <<Patient Demographics:Surname>>	SPECIALIST	
DOB	<<Patient Demographics:DOB>>	Dr David Seaton	
Address	<<Patient Demographics:Full Address>>		
Phone:	<<Patient Demographics:Phone (Mobile)>> <<Patient Demographics:Phone (Home)>>		
Medicare	<<Patient Demographics:Medicare Number>>		

CLINICAL DETAILS

	

ECHOCARDIOGRAM REQUEST (restricted to once every 2years. See QNI Quick Reference Guides for exceptions)
	Initial Comprehensive TTE  55126		Specialist Only - Valvular dysfunction 55127	
	Pericardial effusion, pericarditis or cardiotoxic 55133		Specialist Only - Congenital Heart Disease 55132	
	Other 55134 (please specify): ______________		Exercise Stress Echocardiogram  55141	

NUCLEAR IMAGING REQUEST
	Bone Scan		Amyloid Bone scan	
	Lung V/Q Scan		Parathyroid Scan	
	Thyroid Scan
Some medications can interfere with this study and may need to be ceased. Please contact QNI for instructions.		Gastric Emptying Study
Fast from midnight on the day of the test. Some medications can interfere with this study and may need to be ceased. Please contact QNI for instructions.	
	HIDA (Biliary) Scan
Fast for 4 hours prior to study		Meckel’s Scan
Fast for 4 hours prior to study	
			Mag 3 Renal Scan	

MYOCARDIAL PERFUSION REQUEST (restricted to once every 2years. See QNI Quick Reference Guides for exceptions)
	Myocardial Perfusion Scan (for Medicare eligibility please complete Part A. And Part B.)
No caffeine for 24hours before the test including tea, coffee, cola, chocolate and milo. Fast for 4 hours before the test. Please bring a list of your current medications.	

Part A. Myocardial Perfusion Scan Please select at least one;
	the patient has body habitus or other physical condition/s (including heart rhythm disturbance) to the extent where a stress echocardiography would not provide adequate information	
	the patient is unable to exercise to the extent where a stress echocardiography would not provide adequate information	
	the patient has had a failed stress echocardiography 	
	the patient has had an assessment of undue exertional dyspnoea of uncertain aetiology (specialist or consultant physicians only)	
	the patient has had previous MPS in the last 2years, has been revascularized and has evolving symptoms (specialist or consultant Physicians only – once in a 12month period)	

PART B. Myocardial Perfusion Scan Please select at least one:
	(a.) if the patient displays one or more of the following symptoms of typical or atypical angina:
(i)          constricting discomfort in the:
a.             front of the chest; or
b.             neck; or
c.             shoulders; or
d.             jaw; or
e.             arms; or
(ii)       the patient’s symptoms, as described in subparagraph (3)(a)(i), are precipitated by physical exertion; 
(iii)     the patient’s symptoms, as described in subparagraph (3)(a)(i), are relieved by rest or glyceryl trinitrate within 5 minutes or less; or	
	(b.)   if the patient has known coronary artery disease, and displays one or more symptoms that are suggestive of ischaemia:
(i)          which are not adequately controlled with medical therapy; or
(ii)         which have evolved since the last functional study; or	
	(c.) (i)         assessment indicates that resting 12 lead electrocardiogram changes are consistent with coronary artery disease or ischaemia, in a patient that is without known coronary artery disease; or	
	(c.) (ii)        coronary artery disease related lesions, of uncertain functional significance, which have previously been identified on computed tomography coronary angiography or invasive coronary angiography; or	
	(c.) (iii)       an assessment by a specialist or consultant physician indicates that the patient has possible painless myocardial ischaemia, which includes undue exertional dyspnoea of uncertain aetiology; or	
	(c.) (iv)       a pre-operative assessment of a patient with functional capacity of less than 4 metabolic equivalents, confirming that surgery is intermediate to high risk, and the patient has at least one of following conditions:
a.         ischaemic heart disease or previous myocardial infarction; or
b.        heart failure; or
c.         stroke or transient ischaemic attack; or
d.        renal dysfunction (serum creatinine greater than 70umol/L or 2 mg/dL or a creatinine      clearance of less than 60 mL/min); or
e.         diabetes mellitus requiring insulin therapy: or	
	(c.) (v)         quantification of extent and severity of myocardial ischaemia, before either percutaneous coronary intervention or coronary bypass surgery, to ensure the criteria for intervention are met	
	(c.) (vi)       assessment of relative amounts of ischaemic viable myocardium and non-viable (infarcted) myocardium, in patients with previous myocardial infarction; or	
	(c.) (vii)      assessment of myocardial ischaemia with exercise is required, if a patient with congenital heart lesions has undergone surgery and reversal of ischemia is considered possible; or	
	(c.) (viii)    assessment of myocardial perfusion in a person who is under 17 years old with coronary anomalies, before and after cardiac surgery for congenital heart disease, or where there is a probable or confirmed coronary artery abnormality; or	
	(c.) (ix)       for patients where myocardial perfusion abnormality is suspected but due to the patient’s cognitive capacity or expressive language impairment, it is not possible to accurately assess symptom frequency based on medical history.	

Please Fax referral to 0731394010 or email to admin@qldni.com.au
Referring Physician:	<<Doctor:Name>>
<<Practice/Location:Name>>
<<Practice/Location:Address>>	Telephone: <<Practice/Location:Phone>>
Fax: <<Practice/Location:Fax>>	
Provider No:	<<Doctor:Provider Number>>	Date: <<Miscellaneous:Date>>	
Signature: