Cardiac Rehabilitation / Risk Prevention Referral
Patients name: <PtFullName>	
Address: <PtStreet>, <PtCity>, <PtPostcode>, <PtState>	
DOB: <PtDoB>	Gender: <PtSex>	
Phone: <PtPhoneH>	Mobile: <PtPhoneMob>	

		Cardiac Rehabilitation	OR		Healthy Heart Program (Risk Prevention)	

Hospital Admission	
Location:	Patient ID:	
Please provide details if possible:	
Date of Admission:	Date of Referral:	Date of Discharge:	
	
		CABG		Valve Replacement/Repair		CTCA	
	
		Angio		Stent		ICD	
	
		Pacemaker	

Diagnosis	
	
		ESE +ve/-ve (please circle)		NSTEMI		STEMI	
	
		Angina		Heart Failure		LVEF (%)	
	
		Other (Please provide details)	

Relevant Past History:	
<SelectedPMH>	
Complications:	
<Reactions>	
Limitations:	
	
Medications:	
<SelectedRx>	

Referring Doctor/ Surgeon: <DrName>	
Name of Discharge Nurse:	
Address:  <Practice>, <UsrAddress>	
Phone:  <UsrPhone>	Fax:  <UsrFax>	
Email:  <PracEmail>	Signature:	
Date: <TodaysDate>	Provider No: <DrProviderNo>	
Copy to referring cardiologist: