# 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](mailto: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:***

- **Attachments**