For Medical Practitoners

Our clinic accepts ONLY GP referrals in multiple formats.
The patient is welcome to bring the signed and dated paper referral at the time of their appointment, alternatively, the GP can submit a signed and dated referral via Medical Objects, fax, email or with one of the forms below.

Your GP can submit an online referral form below or find links to our forms available for download in PDF and RTF format below.

Download Referral Form (PDF)

Download Referral Form (RTF)

Online Patient Referral Form

Dr Jilani Latona

MBChB, FRACP Cardiologist
404181GH

Dr Reza Reyaldeen

MBBS, FRACP Cardiologist
6335279A

Patient Details:

Patient's Name:

Mobile Phone:

Address:

Date of Birth:

Medicare Number:

Investigations Requested:

GP & Specialist Referral:

Cardiac consultation Echo - Initial comprehensive (55126) - Rebatable once every 2 years Serial echo pericardial disease/ cardiotoxicity （55133） - No claim limit Exercise stress echocardiogram (55141) - Rebatable once every 2 years Holter monitoring (11716) - Rebatable once every 4 weeks 7-day event monitoring (11723) - Rebatable once every 3 months 30 day event monitor 24-hour blood pressure monitor 12-lead ECG (reported) (11704) - No claim limit

Specialist Referral Only:

Serial echo (55127) Valvular disease - No claim limit Serial echo (55129) Structural heart disease - No claim limit Serial echo for rare cases （55134） - No claim limit Repeat exercise stress echo (55143) - Rebatable once every 12 months

The Australian Government has made changes to Medicare-funded cardiac imaging services, therefore rebates are subject to clinical details that meet Medicare eligibility requirements. For more information please refer to www.mbsonline.gov.au

Clinical Details:

Referring Doctor:

Practice Name:

Provider Number:

Referral date:

Home
Services
Patients
Referrals
About us
Contact us

Home
Services
Patients
Referrals
About us
Contact us

Suite 7, 171 McCullough Street, Sunnybank QLD 4109
reception@brisbanecardiac.com.au
(07) 3188 1515