Cardiologists				
Cardiac Imaging
Dr Philip Currie
Dr Manali Jain	General Cardiologists
Dr Pasko Dedic
Dr Siang Ung	Interventionalists
Dr Richard Clugston
Dr Yuli Ten	Stroke and General
Medicine Physician
Dr Raj Mehta	

For All Appointments & Reports	P: 1300 887 997	E: adminteam@cvs.net.au	EDI: hollspec	

Direct Line for CVS Bunbury: 08 6389 3585	

Patient Name	
	
Date of Birth	

<<Patient Demographics:Full Name>>	
	
<<Patient Demographics:DOB>>	

Phone	
	
Email	

H: <<Patient Demographics:Phone (Home)>>	
M: <<Patient Demographics:Phone (Mobile)>>	

	
<<Patient Demographics:E-mail>>	

Address	

<<Patient Demographics:Full Address>>	

	

Investigations requested	

	
1. ECG (Tracing and Report)	

	
2. Echo (Adult & Paediatric)	

	
3. Holter Monitor (With 12 Lead ECG)	

	
4. Event Monitor (With 12 Lead ECG)	

	
5. Ambulatory Blood Pressure Monitor*	

	

6. Exercise Stress Test	

	
7. Stress Echo (Treadmill) (Includes baseline Echo**)	

	
8. Stress Echo (Dobutamine) (Includes baseline Echo**)	

	

9. Transoesophageal Echo (T.O.E)	

	
10. CARDIOLOGY CONSULTATION	

		Indications For Stress Echo & Exercise Stress Tests	

(please tick one or more options: test does not attract
Medicare rebate if none selected).	

	
Chest Pain	

	
Exertional Symptoms suggestive of heart disease	

	
Ischaemic ECG changes	

	
Functional assessment of CAD detected on Angio/CT	

	
Pre-op assessment for high risk patient (Stress Echo only)	

	
Suspected silent ischaemia (Stress Echo only)	

	
Suspected heritable arrhythmia (Exercise Stress Test only)	

	
Assessment indicates potential non-coronary artery	

disease & stress echo likely to assist diagnosis (specialist or
consultant physician referral only).	

* Medicare rebate only for patients with newly diagnosed Hypertension see
   overleaf for more details
** Baseline echo performed for all stress echos, depending on the patient's
    Medicare eligibility	

Clinical details (Free text area for Doctor to enter patient clinical details.)

Patient history	

	
Hypertension	

	

Dyslipidaemia	

	

Family history	

	

Diabetes	

	

Smoker	

	

Known CAD	

	

Sleep Apnoea	

	

Current Medications	

	
Beta Blocker	

	

Calcium Blocker	

	

ACE Inhibitor	

	

Referring Doctor	
<<Doctor:Name>>
<<Doctor:Full Address>>	

Provider Number: <<Doctor:Provider Number>>	

Referring Doctor Signature:	
Date: <<Miscellaneous:Date>>	

Copy To: <<Addressee:Name>>	

	

Your doctor has recommended that you use CVS for your test. Should you wish to use another provider, please discuss this with your doctor first.	

Please remember: This referral must be presented at your appointment	

Inglewood	Joondalup	Leeming	

Ground Floor, Unit A
826 Beaufort Street
Inglewood WA 6052
PARKING
Free parking available on side streets	Joondalup Health Campus
Specialist Medical Centre (West)
Suite 205, Level 2
Joondalup WA 6027
PARKING
P1 (Pay as you leave parking) - Enter via Shenton Ave
P4 (Pay and display parking) - Enter via Regents Park Rd
Some free street parking available on Regents Park Rd	Suite 3, 73 Calley Drive
(Corner of South Street & Calley Drive)
Leeming WA 6149
PARKING
Free parking onsite and opposite clinic,
at Bull Creek Shopping Centre	
Mandurah	Midland	Nedlands	

Peel Health Campus
Suite 3, South Consult Suites
110 Lakes Road
Mandurah WA 6210
PARKING
Free parking onsite at
Peel Health Campus	Suite 2, Midland Professional Centre
9 The Avenue (Corner of Keane Street)
Midland WA 6056
PARKING
Paid parking available on side streets.
Several City of Swan parking facilities are available
off The Avenue, Keane Street, Old Great Northern Hwy
and Stafford Street	CVS Testing Appointments: Suite 8
CVS Consultant Appointments: Suite 13
Hollywood Specialist Centre
95 Monash Avenue Nedlands WA 6009
PARKING
Paid parking in multistorey carpark via
Entrance 5, Monash Avenue	

Rockingham	

Waikiki Private Hospital
Specialist Centre
Suite 1, 221 Willmott Drive
Waikiki WA 6169
PARKING
Free parking onsite	

Bunbury	

Unit 2, 138 Spencer Street,
Bunbury WA 6230
Direct line: (08) 6389 3585
PARKING
Free parking onsite	

	MBS UPDATE TO CARDIAC IMAGING SERVICES
As of 1st of August 2020, changes to the MBS apply to all cardiac imaging services. All patients will be subject to an online Medicare eligibility check to determine whether they are eligible for a Medicare rebate for the requested test. Restrictions may apply to frequency of tests, requesting physician and clinical indications specific to requested test.
THE MAJOR CHANGES TO CARDIAC TESTING ARE AS FOLLOWS:
•	GPs are able to request repeat or serial transthoracic and stress echos every 24 months that attract a Medicare rebate. For more frequent serial studies, the request must come from a consultant or specialist physician in order to attract a Medicare rebate.
•	Asymptomatic patients and patients who are referred for cardiac 'screening' are not eligible for a Medicare rebate for an Exercise Stress ECG or Stress Echo. To attract a Medicare rebate, one of the specific indications must be selected on the front page of the request form.
•	All stress echos (treadmill and Dobutamine) performed by CVS will include a baseline echo study, dependent on patient's Medicare eligibility. If the patient is not eligible for a baseline echo, a 'stress portion only' study will be performed.
•	Patients who have (or suspected) pericarditis/effusion and patients who are being treated with cardiotoxic medication are eligible for Medicare rebate for serial echo studies requested by an medical practitioner.
•	As of 1st Nov 2021, there is a new MBS item for diagnosis of hypertension through Ambulatory BP monitoring. Eligible for Medicare rebate for diagnosis of hypertension only; patient must not have commenced antihypertensive therapy, and must have in-clinic BP of wither 140-180mmHg systolic or 90-110mmHg diastolic.
Full a full list of all changes, please visit MBS online or contact CVS on 1300 887 997.
CVS	

Cardio Vascular
Services	

ACN 089 068 897
ABN 43 089 068 897	

P:    1300 887 997 (8am-5pm Mon-Fri)
F:    (08) 9389 5322
E:    adminteam@cvs.net.au
W:   https://cvs.net.au
Healthlink EDI:   hollspec
CVS Bunbury Direct Line:
P:    (08) 6389 3585