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Referal Forms

Consultation

4D Echo and Vascular Laboratory
28-02 Fair Lawn Ave
Fair Lawn, NJ 07410
Patient’s Name:
Patient’s Date of Birth:
Physician’s Name:
Physicians signature:
Physician’s Tel:
Physician’s Fax:


CARDIOLOGY CONSULTATION

Reason for the test:

Chest Pain High Cholesterol Hypertension
Shortness of Breath Pre-operative Evaluation Abnormal ECG
Palpitations
Other (please specify)


If available, please fax us all cardiology test results and notes for the patient, latest ECG, Echocardiogram, Stress Tests as well as the latest labs. Our fax number is (201) 475-2221


We appreciate your trust and the opportunity to take care of your patients.