Sunnybank Cardiopulmonary 
DIAGNOSTIC SERVICE	
Ph: 3345 7189
Fax: 3345 8773	

Visiting Specialists
Dr Vagish Singh
Dr Sean Mulhearn
Prof David Colquhoun 
Dr Suhasini Singh 
Dr Sandhir Prasad	

GP referrals 
(Medicare rebate once every 2 years)

☐ Initial Echo 55126 
☐ Exercise Stress Test 11729
☐ Exercise Stress Echo 55141
☐ Myocardial Perfusion Scan
☐ 12-Lead ECG reported 11704/11714
☐ 24-Hour ECG Monitor (Holter) 11716
☐ 24-Hour Blood Pressure Monitor 11607
☐ 7-Day Event Monitor 11723
 	
Specialist referral only 

☐ Serial Echo 55127 (Valvular Disease)
☐ Serial Echo 55129 (Structural Heart Disease)
☐ Repeat Stress Echo 55143 (Rebatable once every 12 months)     
 ☐ Serial Echo 55133/55134 (Pericardial Disease / Cardiotoxicity / Rare cases)	

	

Patient Name

……………………………………………………………………
	
Birth Date

………………………………………………	

Clinical Details
……………………………………………………………………………………

……………………………………………………………………………………

……………………………………………………………………………………

REFERRING DOCTORS DETAILS
Name
……………………………………………………………………………..	
Provider Number
…………………………….	

	

Signature
………………………………………………………….……………..	
Date
…………………………..	

	For appointments please phone: 3345 7189

DATE: ……………………………………………………………………………………………………………………

TIME: ……………………………………………………………………………………………………………………

COST: ……………………………………………………………………………………………………………………

PREPARATION FOR TEST: 

Exercise Test:
Nothing to eat or drink for two hours prior to appointment. Wear comfortable clothing and shoes appropriate for walking. It is preferable for ladies to wear a loose-fitting top. Bring a list of your medications.

Stress Echocardiography:
As per instructions for exercise test.

Holter monitor and 7 day event ECG recording:
Please wear a loose-fitting top. 
Holter monitor only: 
No shower or bath while wearing the monitor.

BP monitor:
Sleeveless or loose short sleeve top. 

ECG: 
No preparation. 

Echocardiography: 
No preparation. 

Myocardial Perfusion Scan (Thallium):
Refer to your instruction sheet. 
	
Suite 11, 2nd Floor, Sunnybank Private Hospital Medical Complex
245 McCullough Street, Sunnybank, QLD 4109
Email: reception@sunnybankcardiopulmonary.com.au	PLEASE BRING THIS REFERRAL WITH YOU TO YOUR APPOINTMENT