Sunecho Referral
Echocardiogram Request - 021 938 4332
Please Note:
All requests must be motivated or approved by a consultant in the following departments:
Medicine (all divisions), Anaesthesiology, Cardio-thoracic Surgery.
Echocardiographic examination will only be considered if the form is properly completed.
Patient Details
Patient's Surname
*
Patient's First Name
*
TBH Number
Date Of Birth
Gender
Male
Female
Weight
Height
Covid-19 Status
Positive
Negative
Not Tested
Ward
Referring Department
Department
Consultant
Referring Doctor
Cellphone / Telephone Number
Email Address
*
Clinical Information
Relevant Clinical Findings
Reason For Echo
Blood Pressure
Heart Rate
Routine
OPD
Urgent (Phone First)
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Sunecho Referral
