Outpatient Cardiac Rehabilitation Referral Form printable pdf download

Outpatient Cardiac Rehabilitation Referral Form

Outpatient Cardiac Rehabilitation Referral

Fax # 678-843-5669 or Phone # 678-843-7633

Patient: ______________________________________________________________

Patient DOB:____________

Patient Phone:_____________________________

Please complete all three areas

Please check if your patient will require a stress test prior to entering Cardiac Rehab:

□ Yes

□ No

 If a stress test is not required we will use a target heart rate of 20-30 bpm

above rest unless otherwise advised.

 Please indicate below if you feel an alternate heart rate range should be used:

___________________________________________________________________

)

Primary Diagnosis During Recent Hospitalization: (select all that apply

□ Coronary Artery Bypass Graft

□ Percutaneous Coronary Intervention

□ Myocardial Infarction

□ Heart Transplant

□ Valve Repair or Replacement

□ Stable Angina

Please provide supporting documents for diagnosis of stable angina)

(

□ Chronic Congestive Heart Failure Chronic heart failure defined as patients with:

(a) EF< 35%

 Please record current EF ____________

(b) NYHA class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks

 Please record NYHA class ____________

or procedure in the next 6 months.

□ Other______________________________________________________________________



I consider this program to be medically necessary for my patient.



After completing Phase III my patient may participate in our minimally supervised

Cardiac Fitness Program if he/she desires.

This referral requires a physician signature. Please do not stamp.

3. MD Signature

___________________________________Date________Time__________

MD Printed Name

___________________________________________________________

Outpatient Cardiac Rehabilitation Referral Form