Referral Form
Questions? Call or text Baton Rouge Cardiology Center at (225) 769-0933.
Patient Information
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
BRCC Number
Patient Email (optional)
example@example.com
Sex (Assigned at Birth)
*
Male
Female
Patient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Other Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Insurance Information (if available)
*
Appointment Request
Reason for Referral - Indication or Diagnosis
*
Specialty Requested
Cardiology
Interventional Cardiology
Electrophysiology
Vascular/Vein
Other
Provider & Location Preferences
Physician Requested
No Preference
First Available
Darrin M. Breaux, MD - Cardiology
Joseph M. Cefalu, MD - Interventional Cardiology
Harold G. Clausen, MD - Interventional Cardiology
Daniel T. Fontenot, MD - Interventional Cardiology
Boyd E. Helm, MD - Interventional Cardiology
Steven E. Kelley, MD - Interventional Cardiology
Benjamin E. Kilpatrick, MD - Cardiology
Lance C. LaMotte, MD - Interventional Cardiology
Steven A. Malosky, MD - Interventional Cardiology
Nakia A. Newsome, MD - Cardiology
Henry C. Patrick, MD - Cardiology & Electrophysiology
Fred H. Petty, MD - Interventional Cardiology
Mark S. Pollet, MD - Electrophysiology
Evens Rodney, MD - Cardiology
Venkat R. Surakanti, MD - Interventional Cardiology
Terry L. Zellmer, MD - Interventional Cardiology
Preferred Office Location
No Preference
Baton Rouge, LA (Brittany Dr.)
Baton Rouge, LA (Summa Ave.)
Baton Rouge, LA (Mid City)
Brusly, LA
Centreville, MS
Denham Springs, LA
Donaldsonville, LA
Gonzales, LA
Lutcher, LA
New Roads, LA
Prairieville, LA
St. Francisville, LA
Walker, LA
Woodville, MS
Zachary, LA (Hwy. 19)
Zachary, LA (Old Scenic Hwy.)
Other
Documents
Submit any pertinent medical records. Fax documents to 225-769-6255.
Completed referral form
Demographics sheet
Insurance card (copy front & back)
History and Physical Examination (H&P)
Laboratory results
Electrocardiogram (EKG)
Other studies (report & images on CD)
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Referring Provider Information
Referring Provider Name
*
First Name
Last Name
Suffix
Practice Name
Referring Provider Email
Office Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referring Provider Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Provider Fax
Please enter a valid phone number.
Format: (000) 000-0000.
National Provider Identifier (NPI)
Primary Care Provider (optional)
*
First Name
Last Name
Suffix
Please verify that you are human
*
Submit
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