HEART OF THE VALLEY PEDIATRIC CARDIOLOGY

5565 W. Las Positas Blvd. Suite 140

Pleasanton, CA 94588
Phone 925-416-6550 Fax 925-397-2193

IDS N CTION Referral From

*Please note this referral form is for your convenience and is not required for our participation
REFERRING PROVIDER INFORMATION
Practice Name Provider Last Name First Name MI

Street Address Specialty

City Zip Code Phone Number

PATIENT INFORMATION
Last Name First Name MI Sex M F

Date of Birth Home Phone Number Work Phone Number

 Hill Physicians  United Health Care  Health Plan San Mateo  Aetna  Palo Alto Medical Foundation
 John Muir  Great West Health Care  San Mateo County Health Center  Cigna
 Bc of California  Bs of California  Medi-Cal of California  Ppmsi  Other
REFERRAL DETAILS
Referral Date Primary Diagnosis:

Indications / Diagnosis

Studies Completed

Current Medication and other Pertinent Information

SIGNATURES
Form sent by (person sending form from Referring Provider)

Form received by (person receiving from on behalf of Specialist)

ATTACHMENTS
AVAILABLE LAB TESTS REPORT OTHER
Specify: Specify:
TC TG Fasting Glc
LDL Lp(a) Fasting Insulin
HDL Homocysteine
Thyroid Screen Liver Function
Specialist’s Comments:

Pleasanton Clinic Fremont Clinic Tracy Clinic

5565 W. Las Positas Blvd, 1895 Mowry Avenue 652 W. 11th Street
Suite 140 Suite 100 Suite 129
Pleasanton, CA 94588 Fremont, CA 94538 Tracy, CA 95376