Online Referral From a Physician to Legacy Heart Center

To refer a patient to a HTPN physician or provider, please complete the information requested below. This is a secure form, and the information you provide will enable us to assist your patient as efficiently as possible.

Requesting an Appointment for Yourself? Use our appointment request form.

Required items are marked with a red asterisk*

Referring Physician Office Information

Referring Physician First Name: *
Referring Physician Last Name: *
Practice Name: *
Address 1: *
Address 2:
City: *
State: *
Zip Code: *
Office Contact Person:
Daytime Phone Number: * (000-000-0000)
Fax Number: * (000-000-0000)
E-Mail Address: *

Patient's Information

Patient's Last Name: *
Patient's First Name: *
Date of Birth: * (mm/dd/yyyy)
Daytime Phone Number: * (000-000-0000)
Our office will contact your patient between 8:30am - 5:00pm, Monday-Friday
Address 1:
Address 2:
Zip Code:
Contact Person (if not patient):
Relationship to Patient (if not patient):

Medical Information

Reason for Referral: *
Preferred Provider:
Name of Provider you would like patient to see.


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Requests are Sent to our appointment Schedule. We will contact the patient within three business days.
We will contact your office with the outcome of this request