Cardiac Referral Home Cardiac Referral CARDIAC REFERRAL FORM Complete this form to refer your patient for cardiac tests. Clinic Select Clinic Gleneagles Hospital HMI Medical Centre Mount Elizabeth Novena Specialist Centre Mount Elizabeth Orchard Medical Centre More information on our Locations Doctor Any Doctor Dr Michael MacDonald Dr Peter Ting Dr Reginald Liew Dr Rohit Khurana More information on our Doctors Bill To Select Bill Clinic Patient Required Test(s) 24-Hr Ambulatory Blood Pressure Monitoring 24-Hr Holter Monitoring 2D Echocardiogram Cardiology Consultation Carotid Intima Media Thickness ECG Exercise Stress Echocardiography Exercise Treadmill Test Renew Others 1 Day 3 Day 5 Day Please describe the other test required Clinical Notes (Optional) Preferred Test Date / Time Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2026 2027 2028 2029 2030 Patient Details Patient Date of Birth Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Gender: Male Female Clinic Details Patient's next appointment with referring doctor Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2026 2027 2028 2029 2030 I understand and agree to the privacy policy . Submit Book a visit Take the first step toward better health today Call the clinic Request appointment
