Refer a Patient — Khan Cardiology

admin@khancardiology.com.au

02 4056 1120

Fax: 02 4989 6460
Medical Objects supported.

Online referral

Referral form

Fields marked * are required.

Referring practitioner

Prefer to receive correspondence via Medical Objects

Full name *

Provider number

Practice / clinic name

Phone *

Email *

Patient details

Patient name *

Date of birth

Patient phone

Medicare number

Preferred location

Urgency *

Reason for referral

Clinical question / reason *

Service requested

Cardiology consultation Echocardiogram Stress echocardiogram Holter / event monitor Coronary angiography

Relevant history / medications

I confirm I have the patient's consent to share these details and to be contacted by Khan Cardiology to arrange an appointment. *

General enquiry instead

For secure clinical correspondence, please also use Medical Objects or fax 02 4989 6460.