Cardiac Physiology Measurement Test Request
ALARM SYMPTOMS: Patient with these symptoms should be referred to hospital as stated:

True unstable angina/suspected MI - phone 999 and admit CCU

Recurrent sudden loss of consciousness without warning (syncope) - urgent referral

New onset/worsening cardiac chest pain – refer to Rapid Access Chest Pain Clinic

New onset heart failure with elevated BNP – refer to Rapid Access Heart Failure Clinic
Patient Details
Name:
Email Address:
First Language:
Address:
Interpreter Required:
]
GP Details
GP Name:
Address:
Date of Birth:
Gender:
Ethnicity:
Tel (Daytime):
Tel (Work):
Tel (Mobile):
NHS No:
Hospital No:
Tel No:
Fax No:
Date of referral:
Practice Code:
Test Request
Direct access Cardiology diagnostic appointments are for patients that only need a single test
(not a range of diagnostic tests and clinical assessment – please referral to general clinics).
For Choose and Book use Speciality – “Diagnostic Physiological Measurement”
24 Hour ECG [Cardiac Test (Not Echo) on CaB]
Echocardiogram [Echocardiography on CaB]
24 Hours Blood Pressure Monitoring [BP Monitoring on CaB]
Does the patient have an infection or risk to others? (tick if yes)
Clinical question you want the test to answer? (mandatory):
Please attach list of current medication & relevant past medical history
Please attach list of current medication & relevant past medical history
Allergies:
Current Medication:
Other Relevant Medical History:
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