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Refer a Patient
Ways to Give
Contact Us
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Doctors
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Pediatric Services
Pediatric Heart Care
Physician Referral
Refer a Pediatric Heart Patient
What is the reason for consultation?
Aortic Arch Hypoplasia
Aortic Stenosis
Arrhythmia
Atrial Septal Defect (ASD)
Bicuspid Aortic Valve
Cardiac Masses
Cardiomyopathy
Congenital Heart Block
Congenital Heart Disease (CHD)
Coarctation of the Aorta
Double Inlet Left Ventricle (DILV)
Double Outlet Right Ventricle (DORV)
Ebstein’s Anomaly
Endocarditis
Hypoplastic Left Heart Syndrome (HCHS)
Hypertrophic Cardiomyopathy
Kawasaki Disease
Mitral Valve Disease
Myocarditis
Pericarditis
Pulmonary Atresia
Pulmonary Stenosis
Rheumatic Heart Disease
Single Ventricle Congenital Heart Defect
Supraventricular Tachycardia (SVT)
Tetralogy of Fallot (ToF)
Total Anomalous Pulmonary Venous Return (TAPVR)
Transposition of the Great Arteries (TGA)
Tricuspid Atresia (TA)
Truncus Arteriosus
Ventricular Septal Defects (VSD)
Other
If other, please specify.
Referring physician information
Is the referring physician from a University Health or UT Health San Antonio affiliated practice?
Yes
No
Referring Physician First Name
Referring Physician Last Name
Referring Physician Email Address
Is the referring physician also the patient's primary care provider (PCP)?
Yes
No
Physician Business Phone
Please include extension if applicable.
Physician Fax
Physician Address
Physician City
Physician Zip or Postal Code
Physician State or Province
Patient information
Patient's First Name
*
Patient's Middle Name
Patient's Last Name
*
Patient's Birth Date
*
Patient's Address
Patient's City
Patient's State
Please Select...
Alaska
Alabama
Arkansas
American Samoa
Arizona
California
Colorado
Connecticut
D.C.
Delaware
Florida
Micronesia
Georgia
Guam
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Marshall Islands
Michigan
Minnesota
Missouri
Marianas
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Palau
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Virgin Islands
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Military Americas
Military Europe/ME/Canada
Military Pacific
Alberta
Manitoba
British Columbia
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
Patient's Zip or Postal Code
Patient's Primary Phone
*
Patient's Email Address
*
Patient's Insurance
*
Patient's Parental Guardian Information
Parental Guardian's Name
*
Parental Guardian's Phone
*
Other Information
Is this referral for fetal?
Yes
No
If yes to the previous question, please provide the Name of OB/GYN or MFM?
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