Cardihab

Evidence based cardiac rehabilitation at your fingertips. Cardihab is delivered via a smartphone app - SmartCR.

Referrer Details

Referring provider name

Referrer role

Phone

Fax

Referral authorisation (please ensure all the fields are completed)

The patient is aware and has given consent for the information within this form to be provided to and to be contracted by the HBF Health Services team

Yes
No

Is the patient an HBF Member?

Yes
No

HBF Member Number

Does the patient have a Smart Phone and access to download apps?

Yes
No

Has the cardiac event happened in the past 60 days?

Yes
No

Referrers Signature:

Date:

Patient Details

Name:

Date of birth:

Address:

Phone:

Email:

Patient Medical Details:

Cardiac event details (including reason for referral, relevant clinical details, risk factors) Other Health Conditions & Relevant Medical History:

Other Health Conditions & Relevant Medical History:

Other: any additional information relevant to referral

Clinical team contacts:

Treating Cardiologist:

Cardiologist Phone:

Cardiologist Clinic/Address:

Regular GP:

GP Phone:

GP Clinic/Address

Find out more about The Cardihab Program

If you wish to discuss a patients suitability and eligibility for The CARDIHAB Program please contact a HBF health coach.

Cardihab

Find out more about The Cardihab Program

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