Heart Transplant Referral Request

Heart/KidneyHeartVAD (Ventricular Assist Device)
Referred To Specific Physician
Physicians Full Name*
Patient Information (All Fields Required)
MaleFemale
Name*

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SSN*
Phone *
Please enter a valid phone number.Format: (000) 000-0000.
DOB*

MonthDayYear
Age*
Height*
Weight*
Dialysis Type*
Dialysis Days*
Unit Phone (Dialysis Unit Phone)*
Please enter a valid phone number.Format: (000) 000-0000.
Unit Name (Dialysis Unit Name)*
Dialysis Date (1st Start Date, Enter 00/00/0000 if not started):*

MonthDayYear
Reason For Referral*
Diagnosis*
Recent H & PList of current medicationsAdmission & Discharge Summary (Within 1 year)Cardiac Catheterization ResultsChemistry/ Hematology Results (Current/within 1 year)CXR, EKG & CT ReportsMost recent ECHO/MUGAS/PTCAThallium/Stress Test ResultsSend films: (Mail to address below) *Operative reports (Cardiac/Pulmonary/Abdominal)Specialist Consultations, & Pathology ReportsCystic Fibrosis Patients only: genetic testing & CF database ID#Related Pulmonary Testing/Procedures: (PFT/Desat Test 6 min walk)Office Notes (Last 6 months)
Referring Physician Information
Referring MD.*
Referring MD. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax*
Please enter a valid phone number.Format: (000) 000-0000.
Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Primary Care Physician Information
PCP*
PCP Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax*
Please enter a valid phone number.Format: (000) 000-0000.
Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Primary Insurance
Insurance Co*
Insured*
Insured DOB*

MonthDayYear
Policy #*
Group#*
Phone #*
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Insurance
Insurance Co*
Insured*
Insured DOB*

MonthDayYear
Policy #*
Group#*
Phone #*
Please enter a valid phone number.Format: (000) 000-0000.
Faxed referrals or records can be sent to 813-844-5763 or emailed to HVIheartfailurereferral@tgh.org. Referrals can be called in to 813-844-5905.

*Mail Films to: TGH/Transplant Services HMT 5th Floor P.O. BOX 1289, Tampa, FL 33601
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