HEALTHCARE PROVIDERS: North Star Cardiology’s referral forms can be found on our “Providers” page here REQUEST A REFERRAL Use this form to send a referral request to your healthcare provider Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Referral Request Tool Disclaimer - Step 1 of 6Referral Request Tool North Star Cardiology Clinic's Referral Request Tool is a user-friendly online service designed to make the referral process to our clinic as smooth as possible. By guiding you through a series of questions, it collects the necessary information to prepare a referral request tailored to your needs. Once you've completed the questions, you have the option to send the referral request to your healthcare provider via email or fax, based on the contact information you provide. This tool is aimed at enhancing your experience and fast-tracking your access to specialized pediatric or fetal cardiac care. Disclaimer Use and Limitations: No Guarantee of Referral: Utilizing the North Star Cardiology Clinic's Referral Request Tool does not ensure the initiation of a referral to our clinic. We recommend users to follow up with their healthcare provider to confirm the referral process is complete. Data Privacy and Security: If you opt to send your referral request via email, please be aware that North Star Cardiology will not keep a copy or record of your request. However, if you choose the fax option, your request will be securely stored in an account protected by password and two-factor authentication, ensuring the highest level of data privacy. Under no circumstances will this information be shared with third parties. User Discretion Advised: The decision to use this tool lies with the user. North Star Cardiology Clinic assumes no responsibility for any misuse of the form. Accuracy of Information: It is crucial to verify the information you input, particularly the email address or fax number of your healthcare provider. North Star Cardiology is not liable for referral requests sent to incorrect recipients due to user error. By using this tool, you acknowledge and consent to these terms. Your engagement in the referral process is essential, and we at North Star Cardiology are dedicated to supporting you every step of the way. For further information or assistance, please reach out to us directly. Acknowledgement *I have read and agree to the Use and Limitations as outlined aboveConsent for ContactI give permission to North Star Cardiology to contact me in the futureContinueWho is this referral for? *I am requesting a referral for myself (I am pregnant)I am a parent/guardian requesting a referral for my childPatient Name *FirstMiddleLastYour Name *FirstMiddleLastPhone Number *Email *PreviousContinueWhat is the reason for this referral request? *My child has been diagnosed with a heart conditionMy child is having symptomsFamily history of heart problems (screening)My child has a genetic condition (screening)Please select your child's medical condition: *Select all that applyCongenital heart defectCardiomyopathyArrhythmiaOtherOther *What symptom(s) is your child experiencing?Select all that applyChest painPalpitationsLightheadednessFaintingShortness of breathTurning blueOtherOther *Please describe the family history: *Please describe the genetic condition: *Please select the reason for your referral request: *Select all that applyI became pregnant with the help of IVFI have diabetes since before I was pregnantI was diagnosed with diabetes before 26 weeks gestation (with HbA1C >6% or unknown)I have phenylketonuriaI have lupus, Sjogren syndrome, or SSA/SSB antibodiesI had a rubella infection during before 14 weeks gestationI had pericarditis or myocarditis during this pregnancyI or the father have a congenital heart defect (including hole in the heart, abnormal valves, or other)I or the father have a cardiomyopathyI or the father have a 1st degree relative with congenital heart disease (including hole in the heart, abnormal valves, or other)I used one of the following medications: retinoids, NSAIDs, ACE inhibitors, paroxetine, anticonvulsants, or lithium)I or my partner has a genetic condition associated with risk of heart conditionsMy First Trimester Screen or Invitae test were high riskMy baby is suspected to have a heart problemMy baby has been diagnosed with hydrops (swelling in their body)My baby has been diagnosed with a non-heart anomalyMy baby’s heart rhythm was abnormal (including fast, slow, or irregular)My baby has been diagnosed with a genetic conditionMy baby had a nuchal translucency of 3 mm or moreMy baby has a single umbilical arteryI am having more than one baby (ie. twins, triplets, etc.)OtherOther *How far along in your pregnancy are you? (number of weeks) *Go BackContinueHealthcare Provider's Name *FirstLastClinic or Hospital NameHow would you like to request a referral from your healthcare provider?EmailFaxEmail *Fax Number *Go BackContinueAdditional CommentsGo BackContinueUpdating preview…Review and Confirmation of Details *I have reviewed and confirmed the details of my submission and wish to proceed with sending a referral request to the healthcare provider's email or fax I entered.Go BackSubmit
