For Referring Physicians

Referring physicians can now order diagnostic tests or refer patients to Coastal Cardiology online! Just fill out the form below, and it will generate an email to one of our staff. Our staff will then contact the patient to make an appointment.

Please fax additional medical records to: (805)782-8859. We need records such as: Last Chart Notes, Medication List, ECG, Treadmill with Tracings, Echocardiogram, Holter Monitor, Lab-cholesterol Panel and most recent labs, Chest x-ray, Angiogram / Angioplasty (PTCA) bypass, copy of insurance cards and a current patient registration form. Please indicate in the additional comments field what records are being faxed including date and time the fax was sent.

Patient Last, First Name:
Patient Date of Birth:
Patient Phone Number:
Insurance Company:
Insurance Plan:	Private Insurance CMSP EPO HMO PPO Medicare SLO Select IPA State of CA Workers Comp
Authorization Number :
Referring Physician:
Primary Diagnosis:
Secondary Diagnosis:
Procedure Request:	Consultation Stress Echocardiogram Nuclear Stress Test Arterial Ultrasound Venous Ultrasound Ambulatory ECG Monitoring (24 hr Holter Monitor) Ambulatory Blood Pressure Monitoring Electrocardiogram (EKG) Echocardiogram Carotid Duplex Event Recorder Renal Ultrasound Abdominal Ultrasound
	*Please be sure to send the requested information listed above.
Additional Comments:
Referring Contact:
Referral Contact Number:
Referral Contact Email: