Make Appointment — Sydney Heart Team
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Home
/
Who we are
/
What we do
/
Innovation
/
Make Appointment
/
Contact
/
Sydney Heart Team
Make Appointment
Home
/
Who we are
/
What we do
/
Innovation
/
Make Appointment
/
Contact
/
So that we can help your patient effectively, please complete the referral form below. However, if you need to discuss your patient with Dr Martin Ng before referring, please
EMAIL
him a few brief details and he will call you back.
Required Information
Full Name
*
First Name
Last Name
DOB:
*
Male
Female
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
Optional Information
Interpreter required?
Yes
No
Language
Referring Doctor
Heart condition
Coronary artery disease
Aortic valve disease
Mitral valve disease
Other heart valve disease
Left atrial appendage closure
Other
If other please specify
Is this procedure urgent?
Elective
In-patient - Hospital
Urgent
Summary of cardiac status
Coronary Artery Disease
Yes
No
Unkown
Left Ventricle function
Normal
Mild impairment
Moderate impairment
Sever impairment
NYHA functional class
0
I
II
III
IV
LVEF %
Previous Cardiac Surgery
CABG
Valve Surgery
AVR
MVR
Other
If other please specify
Summary of comobid status
Cerebrovascular disease (CVA, TIA, previous carotid surgery, carotid lesion > 79%)
Airway Disease (COPD, Asthma)
Chronic Renal Failure: Creatinine
Diabetes
Anticoagulant
Mobility impairment
Other
If other please specify
Thank you!
