Stanford Health Care (SHC) - Stanford Medical Center ...
Heart Failure Clinic Referral Form (Items with ** are required for processing271793192405 )? Routine (within 1 month) ? URGENT (within 1 week)-1714501383665Interpreter Needed??Yes ? No Preferred Language: 0Interpreter Needed??Yes ? No Preferred Language: Patient Information Last Name, First Name** DOB**Gender** ? Male ? Female Phone**Address** City** State** ZIP Code** Secondary Contact: Reason for ReferralCardiac Diagnosis/ ICD 10 (list all) **Date of last Echocardiogram**Ejection Fraction**Date of last NT-proBNP or BNP**Result**Previous Cardiac Testing & date (i.e. angiogram, catheterization) **Physician Requested: If physician requested is unavailable, can patient be seen by another provider? ? Yes ? No, contact referring providerService Requested** ?Heart Failure Consult ? Heart Failure 2nd Opinion ? VAD/ Transplant Evaluation ? Arrhythmia Management ? Cardiothoracic Surgery ? Cardiac Oncology ? Amyloidosis ? General Cardiology Referring Provider Information Referring Provider Name** PCP Name Practice Name** Office Address** City** State** ZIP Code** NPI Number Phone** Fax** Provider Specialty ................
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