Brigham and Women’s Cardiovascular Associates at Care New England
□ 90 Plain Street - Providence
□ 111 Brewster Street - Pawtucket
Telephone:
□ 390 Toll Gate Road - Warwick
Fax:
□ Consultation □ Cardiac Testing → □ STAT
□ Urgent (within 48 hrs)
□ Elective
Patient Name _________________________________________________________ DOB ___________
□ Male □ Female Primary Language _________________________ Interpreter Needed □ Yes □ No
Address ______________________________________________________________________________
Home Phone _________________ Mobile Phone _________________ Work Phone _________________
Primary Insurance _________________________________________ Policy # ______________________
SYMPTOMS
CONDITIONS
TESTING
□ Chest Pain
□ Syncope
□ Murmur
□ Dyspnea
□ Palipitations
□ Visual Disturbance
□ Abnormal EKG
□ Weakness / Malaise
□ Headache
□ Other _________________________
________________________________
□ Coronary Disease
□ Bradycardia
□ Lipid Disorder
□ Heart Failure
□ Vascular Disease
□ Metabolic Syndrome
□ Congenital Disease
□ Tachycardia
□ Hypertension
□ Other _________________________
________________________________
□ EKG
□ Stress Test (Regular ETT)
□ Nuclear Stress Test
□ Cardiolite
□ Persantine
□ Dobutamine
□ Echocardiogram
□ Stress Echocardiogram
□ Dobutamine Stress Echocardiogram
□ Holter Monitor
□ Cardiac Event Monitor
□ EEG
□ Non-Invasive Vascular Studies
□ Upper extremities
□ Lower extremities
Ordering Provider ________________________________________ cc ___________________________
Office Phone __________________________________ Pager/Cell _______________________________
Signature _______________________________________________ Date _________________________
THANK YOU FOR YOUR REFERRAL
WE VALUE THE OPPORTUNITY TO PARTICIPATE IN THE CARE OF YOUR PATIENT
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Brigham and Women’s Cardiovascular Associates at Care New England
Outpatient Evaluation / Consultation
Diagnostic Testing
Inpatient Care
Clinical Research Studies
Advanced Heart Failure Program
Telemedicine
Arrhythmia Service
Advanced Valvular Heart Disease Clinic
Directions to Warwick site from the North: Take I-95 South to Exit 10B onto Rt. 117 West. At the first traffic light turn
right onto Commonwealth Avenue. At stop sign turn right onto Leon Whipple Road. See sign on right for 390 Toll Gate Road
– turn into driveway and enter parking lot. (If you miss the entrance from Leon Whipple Road, continue straight to Toll Gate
Road. Turn right onto Toll Gate Road. 390 Toll Gate Road is on the right.)
Directions to Warwick site from the South: Take I-95 North to Exit 10 onto Rt. 117 East. At the second traffic light turn left
onto Toll Gate Road. 390 Toll Gate Road is on the left.
Directions to Pawtucket site from the North: Take I-95 South to Exit 27. At the top of the exit ramp turn left at the light onto
East Avenue. At the second light turn left onto Division Street. Go through one light, then turn left just before the second light.
Continue to Pond Street and turn left. Go up the hill and through one light, and take the first right onto Brewster Street. Follow
signs to the main entrance of Memorial Hospital.
Directions to Pawtucket site from the South: Take I-95 North to Exit 28. Turn right onto School Street. At second light turn
left onto Pond Street. Go up the hill and through one light and take the first right onto Brewster Street. Follow signs to the main
entrance of Memorial Hospital.
Directions to Providence site from the North: Take I-95 South to Exit 19, Eddy Street. Bear right on the exit ramp toward
Borden Street. At the stop sign turn right onto Borden Street. Take the next right onto Crary Street. 90 Plain Street is on the
right.
Directions to Providence site from the South: Take I-95 North to Exit 20, Point Street. Stay to the left on the exit. At the
sencond set of lights turn left onto Clifford Street. At the next light turn left onto West Franklin Street. (Stay to the right.) Go
through the next light onto Plain Street. (Stay to the right.) At the stop sign turn left onto Crary Street. Turn left again into the
parking lot for 90 Plain Street.
Directions to Providence site from R-195 West: Take 195-W to Exit 1A, Point Street. Stay to the left on the exit. At the
second set of lightsturn left onto Clifford Street. At the next light turn left onto West Franklin Street. (Stay to the right.) Go
through the next light onto Plain Street. (Stay to the right.) At the stop sign turn left onto Crary Street. Turn left again into the
parking lot for 90 Plain Street.
Telephone:
Fax: