Referral Request Form
Westlake
South Austin
Bastrop
5656 Bee Caves Rd.
Suite M-300
Austin, Texas 78746
tel | 512.445.5998
fax | 512.623.5005
4207 James Casey Street
Suite 215
Austin, Texas 78745
tel | 512.445.5998
fax | 512.443.4388
3101 Hwy 71E
Suite 210
Bastrop, Texas 78602
tel | 512.308.1415
fax | 512.308.1399
Preferred Cardiologist
James B. Williams, MD
Thomas C. Baldacchino, MD
Jennifer Farroni, ANP
Eric J. Frischhertz, M.D.
Samuel J. DeMaio, MD
Kathryn Machuga, FNP
EP Consult
Osvaldo Steven Gigliotti, M.D.
Marcy Smith, ANP
First Available Physician
Patient Information
* Patient Name
Phone
-
-
Date of Birth
m
d
y
Referring Physician information
* Referring Physician
Phone
-
-
Fax
-
-
Primary Insurance
Auth #
** Please fax | deliver pertinent medical records to Capital Cardiovascular Specialists
Patient Evaluation Request
Consultation
Second Opinion
Cardiac Clearance
Diagnostic Test Only
Appointment Priority:
Immediate, please call us
(512)445-5998
2-3 days
Within 1 week
Diagnostic Testing Requested
Nuclear Imaging
2D/ Doppler Echocardiogram (Transthoracic)
ECG with interp
Event Monitoring
Holter monitor
Pacer and ICD Check
Transesophageal Echocardiogram
Treadmill Stress Echocardiogram
CT Angiography of the
Other
MUGA
Treadmill Stress Nuclear
Dobutamine Stress Nuclear
Adenosine Stress Nuclear
Vascular Services
Carotid Duplex
Renal Duplex
LE Duplex
Lower Extremity Arterial; arterial brachial index
with segmental pressures lower extremity
Reason For Referral
Abnormal EKG
Chest Pain
Hypertension
Syncope
Abnormal Stress
Test
CHF
Lipid
Management
TIA
Arrhythmia
Claudication
Murmur
Valvular Heart
Disease
Bruit
Congenital Heart
Disease
Pacer/Defibrillator
Other
CAD
Dyspnea
Palpitations
Cardiomyopathy
Exercise intolerance
Peripheral vasc
disease
Carotid Disease
Heart enlargement
Reno-vasc Disease
