Keshav Chander, MD Cardiologist
Renu Mahajan, MD Internist/Primary Care
8970 W Tropicana Suite 6 Las Vegas, NV 89147
Tel: 702 473 5333
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Provider Referral

 

Smart Heart Care

Keshav Chander MD, Heart Specialist

Board Certified in Cardiology, Adult Echo & Nuclear Cardiology

8970 W. Tropicana Ave Ste 6Las VegasNV 89147

Fax 702-473-5444 Phone 702-473-5333 Website: www.4smartcare.com

 

 

 

Patient Referral Form

 

Name:

DOB:

Home Phone: Cell:

Address:

 

Primary Insurance:

ID#

Secondary Insurance:

ID#

Referring MD:

Phone: Fax:

 

Reason for consultation

Diagnosis:

 

 

□ Consult and Treatment □ Stress Echo

□ Exercise Treadmill Test □ Echocardiogram

□ Heart Monitor □ Exercise Nuclear Stress Test

□ Lexiscan Nuclear Stress Test □ Other

How does the referring provider prefer to receive reports on his/her patients?

□ Email, if yes email address______________________________________

□ Fax, if yes fax # ______________________________________________

□ Phone call or text from our doctor, if yes phone #____________________

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