Refer a Patient

Complete the form below or fax to (03) 5292 9300

Please complete the referral form below. All fields marked with an asterisk are required. Alternatively, fax a referral/request to (03) 5292 9300 or email info@pulsecardiology.com.au.

Cardiologist

Patient Type

Preferred Cardiologist

Referring Doctor

Referring doctor first name *

Referring doctor last name *

Referring practice name *

Referring doctor phone *

Referring doctor fax

Referring doctor email

Providing your email allows us to contact you directly about this referral.

Referring doctor provider number

Patient Details

Patient first name *

Patient last name *

Patient date of birth *

Patient phone *

Patient email

Referral Details

Reason for referral *

Urgency

Attachments

Upload File (referral letter, ECG, or other document)

Accepted: PDF, JPG, PNG, Word. Max 4 MB.

✉ For larger or additional files, email info@pulsecardiology.com.au or fax (03) 5292 9300

Your referral will be sent to info@pulsecardiology.com.au