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 #____________________