Referral Forms

Tamworth Heart Clinic

40 Piper St (Tamara Consulting Rooms)

TAMWORTH NSW 2340

Phone 02 6766 3299

Fax 6761 2665

Could:   Dr Tristam Smyth  Dr Helen Lammi  Please see

Patient Name:............................................................................................

Patient D.O.B:.............................................................................................

Contact Details:...........................................................................................

For:

Consultation            

ECG

Exercise (stress) ECG

24 Hour Ambulatory ECG (Holter) Monitor

Spirometry

Pacemaker check

Additional information:...............................................................................

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Referring Doctor..........................................................................................

Signature.....................................................................................................

Date............................................................................................................

FOR URGENT APPOINTMENTS, DOCTOR IS ASKED TO TELEPHONE TO ARRANGE BOOKINGS

Tristam Smyth TA Helen Lammi and Tristam Smyth Medical Practitioners ABN: 93 100 599 353