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South Asian Heart Center Referral South Asian Heart Center | p 650-940-7242 | f 650-966-9269 | www.southasianheartcenter.org Non-profit, 501(c)3, ID: 94-2823235 To be completed by the physician’s office _______________________________________ met with____________________________________ on ______________________ Participant Last name, First name Name of physician Date ______________________________________________________________________ ___________________________________ Participant email Participant daytime/mobile phone ____________________________________________________________________________________________________________ Participant address (Street, City, State, Zip) Height: ___________ ft. __________ in. Weight: ____________ lbs. Waist Circumference:______________in. i Blood Pressure: ___________ / __________ HR: ___________________ bpm DOB: ___________________________ Special Instructions: __________________________________________________________________________________________ COMPLETE AND FAX THIS FORM TO THE SOUTH ASIAN HEART CENTER AT 650-966-9269. Participant instructions ❏ Complete your advanced laboratory work if requested by your physician. ❏ Sign up online for your screening and TLC program at the South Asian Heart Center, www.southasianheartcenter.org/getscreened. Make sure to enter the name of the referring physician. Call 650-940-7242 to schedule your screening appointments. ❏ Improve your heart health with lifestyle counseling and ongoing heart health coaching. Use the South Asian Heart Center’s exercise, nutrition, and stress reduction experts to develop your personalized lifestyle plan. The South Asian Heart Center at El Camino Hospital in Mountain View offers a comprehensive Advanced Screening and Therapeutic Lifestyle Changes (TLC) program to help participants understand their true risk factors, prevent the onset of diabetes, and reduce the likelihood of having a heart attack. The Center is a unique, non-profit response to the epidemic of heart disease and diabetes in South Asians, i.e., those who trace their origins to India, Pakistan, Bangladesh, Sri Lanka, and Nepal. Form 6830 Rev. 7/12

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Page 1: For Physicians: Patient Referral Form

South Asian Heart Center Referral South Asian Heart Center | p 650-940-7242 | f 650-966-9269 | www.southasianheartcenter.org Non-profit, 501(c)3, ID: 94-2823235

To be completed by the physician’s office

_______________________________________ met with____________________________________ on ______________________ on Participant Last name, First name Name of physician Date

______________________________________________________________________ ___________________________________ Participant email Participant daytime/mobile phone

____________________________________________________________________________________________________________ Participant address (Street, City, State, Zip)

Height: ___________ ft. __________ in. Weight: ____________ lbs. Waist Circumference:______________in. in.

Blood Pressure: ___________ / __________ HR: ___________________ bpm DOB: ___________________________

Special Instructions: __________________________________________________________________________________________

COMPLETE AND FAX THIS FORM TO THE SOUTH ASIAN HEART CENTER AT 650-966-9269.

Participant instructions ❏ Complete your advanced laboratory work if requested by your physician. ❏ Sign up online for your screening and TLC program at the South Asian Heart Center, www.southasianheartcenter.org/getscreened. Make sure

to enter the name of the referring physician. Call 650-940-7242 to schedule your screening appointments. ❏ Improve your heart health with lifestyle counseling and ongoing heart health coaching. Use the South Asian Heart Center’s exercise, nutrition,

and stress reduction experts to develop your personalized lifestyle plan. The South Asian Heart Center at El Camino Hospital in Mountain View offers a comprehensive Advanced Screening and Therapeutic Lifestyle Changes (TLC) program to help participants understand their true risk factors, prevent the onset of diabetes, and reduce the likelihood of having a heart attack. The Center is a unique, non-profit response to the epidemic of heart disease and diabetes in South Asians, i.e., those who trace their origins to India, Pakistan, Bangladesh, Sri Lanka, and Nepal.

South Asian Heart Center Referral South Asian Heart Center | p 650-940-7242 | f 650-966-9269 | www.southasianheartcenter.org Non-profit, 501(c)3, ID: 94-2823235

To be completed by the physician’s office

_______________________________________ met with____________________________________ on ______________________ on Participant Last name, First name Name of physician Date

______________________________________________________________________ ___________________________________ Participant email Participant daytime/mobile phone

____________________________________________________________________________________________________________ Participant address (Street, City, State, Zip)

Height: ___________ ft. __________ in. Weight: ____________ lbs. Waist Circumference:______________in. in.

Blood Pressure: ___________ / __________ HR: ___________________ bpm DOB: ___________________________

Special Instructions: __________________________________________________________________________________________

COMPLETE AND FAX THIS FORM TO THE SOUTH ASIAN HEART CENTER AT 650-966-9269.

Participant instructions ❏ Complete your advanced laboratory work if requested by your physician. ❏ Sign up online for your screening and TLC program at the South Asian Heart Center, www.southasianheartcenter.org/getscreened. Make sure

to enter the name of the referring physician. Call 650-940-7242 to schedule your screening appointments. ❏ Improve your heart health with lifestyle counseling and ongoing heart health coaching. Use the South Asian Heart Center’s exercise, nutrition,

and stress reduction experts to develop your personalized lifestyle plan. The South Asian Heart Center at El Camino Hospital in Mountain View offers a comprehensive Advanced Screening and Therapeutic Lifestyle Changes (TLC) program to help participants understand their true risk factors, prevent the onset of diabetes, and reduce the likelihood of having a heart attack. The Center is a unique, non-profit response to the epidemic of heart disease and diabetes in South Asians, i.e., those who trace their origins to India, Pakistan, Bangladesh, Sri Lanka, and Nepal.

Form 6830 Rev. 7/12

Form 6830 Rev. 7/12

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