For further information or assistance regarding referrals to the Cardiac Rehabilitation Program, please contact any one of our convenient locations.

Please note the following:
  • This form is to be completed by a referring physician.
  • A representative from the Cardiac Rehabilitation Program will contact you within one business day.
  • If you would rather download a form that you can fill out and fax to us, click here.
 
(* = Required)
Patient Information:
   * Name:
Address:
  Date of Birth:
* Phone:
Referring Physician Information:
  * Physician Name:
Practice Name:
  * Phone:
Email Address:
* Preferred Means of Communication: Phone   Fax   Email
Reason for Referral:
  Cardiomyopathy
CHF
MI
PCI
Stable Angina
   Cardiac Surgery:
  CABG
Cardiac Valve
Cardiac Transplantation

Enter code shown above:
 

 

Note: If you would rather download a form that you can fill out and fax to us, use the link below:

Cardiac Rehabilitation Referral Form (PDF Format)

Upon discharge, please fax referral to patient’s preferred site:

Hartford Hospital
Phone: 860.545.2133
Fax: 860.545.3352
Farmington Cardiac Rehabilitation
Phone: 860.696.0080
Fax: 860.696.0085
Glastonbury Wellness Center
Phone: 860.633.9084
Fax: 860.633.9204