Refer a Patient

Refer a qualifying patient to our Virtual Cardiac and Pulmonary Rehab program in less than 30 seconds. For enquiries please contact the Carda Health team at info@cardahealth.com

Carda Website Referral Form

• Patient Name*
• Patient Phone Number*
  Format: (000) 000-0000.
• Patient DOB*
  -Month -Day Year
• Patient Email
• Referral Type*
  • Cardiac Rehabilitation
  • Pulmonary Rehabilitation
• Pulmonary Diagnosis
  • J41.1 Mucopurulent chronic bronchitis
  • J41.8 Mixed simple and mucopurulent chronic bronchitis
  • J43.0 Unilateral pulmonary emphysema [MacLeod's syndrome]
  • J43.1 Panlobular emphysema
  • J43.2 Centrilobular emphysema
  • J43.8 Other emphysema
  • J44.0 Chronic obstructive pulmonary disease (acute) with lower respiratory infection
  • J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
  • J44.89 Other specified chronic obstructive pulmonary disease
  • J44.9 Chronic obstructive pulmonary disease, unspecified
  • U09.9 and R06.00 Post COVID-19 condition, unspecified
• Cardiac Diagnosis
  • MI within the last 12 months
  • Stable Angina
  • PCI
  • CHF (with reduced EF)
  • CABG
  • Valve Repair/Replacement
  • Other
• Cardiac Diagnosis Code
• Please check to include
  • Remote patient monitoring (RPM) of blood pressure and heart rate
• Additional Referral Notes
• Referring Physician Name*
• Office Phone Number*
  Format: (000) 000-0000.
• Referring Physician email
• Referring Signature:

!