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.
Blood Pressure: ___________
/ __________ HR:
Weight: ____________ lbs.
Waist Circumference:______________ in.
___________________ bpm
DOB:
i
___________________________
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
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.
Blood Pressure: ___________
/ __________ HR:
Weight: ____________ lbs.
Waist Circumference:______________ in.
___________________ 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
i