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Contrast / Bubble Echocardiogram
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Email
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Your email
Referrer's NAME
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Patient's FULLNAME
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Patient's DATE OF BIRTH
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Patient's TELEPHONE
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Patient's EMAIL or other contact details
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Self-paying or Insured
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Self-paying
WPA
AXA
DCA
Cigna
Vitality
Allianz
Aetna
SAGA
Aviva
Healix
The Exeter
BUPA
OTHER
Preferred test
*
As per Dr Cheong's recommendation (based on clinical question provided)
Contrast echocardiogram
Bubble echocardiogram
Clinical history / question
*
Assessment of LV ejection fraction
Assessment of LV thrombus
Assessment of intracardiac shunt / stroke ?paradoxical embolism
Other:
Preferred procedure location
*
London
Kent
Required
Any other relevant information (or please forward clinic letter / other documents to enquiries@jcheong.com)
Provide insurance number (if applicable)
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