HealthLink EDI: myhcardi
Fax: 03 9854 6445
Fax
03 9854 6444
Phone
Locations
Locations
Email
referral@myheartcardiology.com.au

POTS Referral Form

FOR DOCTORS
Patient Information:
Name: *
Date of Birth: *
Medicare number: *
Reference number: *
Phone/Mobile: *
Address *
Referral Information
Referral Type - Please note that POTS service is ONLY offered at Coburg site *
Reason for Referral
Write here any other reasons:
Current Medications
Symptoms ( brief ):
Relevant Medical History:

Please attach ALL available investigations:
- Echocardiogram
- Stress Test / Exercise ECG
- Holter Monitor Report
- Blood test results (FBE, iron studies, B12, TSH, cortisol, etc.)
- Imaging reports (e.g., CT, MRI)
- Any relevant specialist letters or documentation

Attach files here:
Maximum file size: 4 MB
Referring Practitioner Details:
Name: *
Provider Number: *
Phone:
Email
Clinic Name:
Clinic Address:
Please sign the form using the signature area below:
Signature: *
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