Patient Detail Form Please complete the online form and then submit.You can also download the PDF format. Patient Referral Form Download Form Please enable JavaScript in your browser to complete this form.Patient Name *Patient Date of Birth *Patient Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryEmail *Home Phone Patient Phone * No. Address Layout Name of GPMedicare No.Ref NoPrivate Health Insurance FundInsurance Fund No.DVA No.Next of Kin NamePhoneRelationshipTerms & Conditions I understand that Dr Rudd Cardiology does not provide urgent or emergency cardiac care. If I experience chest pain lasting more than 10 minutes, I will call 000 immediatelyfor an ambulance. I understand that Dr Rudd Cardiology provides cardiac services onlyand that any non-cardiac causesor investigations related to my symptoms must be discussed with my GP. I understand that my GP is my primary point of contactfor any deterioration in my condition, and in emergencies I should attend the nearest Emergency Department. I understand that bulk-billed cardiac investigations(Holter, ECG, Echo, and Stress Echo) are available to eligible patients. private consultation fees applyif not eligible . I understand that bulk-billed consultationsare limited and available only to eligible patients. I understand that a valid referralis required to qualify for bulk billing and that it is my responsibilityto provide this to Dr Rudd Cardiology before my appointment. I understand that private consultation fees applyfor patients seeking second opinionsor interpretation of cardiac investigations not performed by Dr Rudd Cardiology. I understand that an administration feewill apply if Dr Rudd Cardiology must retrieve my investigation reportsthat were not received prior to my appointment. I understand that a cancellation fee of AUD $300applies if I cancel, reschedule, fail to attend, or arrive lateto my appointment within 48 hours of the scheduled time. I understand that I must arrive at least 15 minutes priorto my appointment time. I understand that the Holter monitor must be returned by 9:00 AMon the agreed return date. A late return fee of AUD $300 per dayapplies for any delay. If I am unable to return it personally, I may arrange for a family member, friend, or courier (e.g., Uber Parcel)to deliver it before 9:00 AM. In the event of an overdue account, I agree to be liable for all costs incurred in full, including legal demand fees. Overdue accountswill be subject to interest at 25% per annum, calculated for the period the account remains unpaid. I confirm that I have been advised of consultation costs, including those for telehealth services. I have read, understood, and agreeto abide by all the above terms and conditions. I consent to Dr Rudd Cardiologyobtaining and sharing information relevant to my medical condition as required for my care. Consent *I agree to all the Terms and Conditions mentioned above.Signature Clear Signature Submit EMERGENCY CASES 1800 37 7833(1800 DR RUDD) OR APPOINTMENTS Fax: +61 3 8080 3250 | M: 0480 017 833 (Text only) OPENING HOURSMon – Fri : 8:00 AM to 6:00 PM | Sat – Sun : Closed