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
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Name: |
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DOB: |
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Home Phone: Cell: |
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Address:
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Primary Insurance: ID# Secondary Insurance: ID# |
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Referring MD: |
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Phone: Fax: |
Reason for consultation
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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 #____________________
© Chander PLLC. 
