How to Send a Patient

Online Referral Form

Send a patient
in under 2 minutes

Fields marked * are required.

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Referral Received

Thank you. We will contact your patient within one business day to schedule their appointment. A copy of the cardiologist report will be sent to the email address you provided.

Urgent referral? Call us directly: (207) 409-7797

Your Information

Physician Name *

Practice / Institution *

Your Email *

Your Phone

Patient Information

Patient Full Name *

Date of Birth *

Patient Phone *

Patient Email

Scan Requested *

Echocardiogram Carotid Duplex AAA Screening (Abdominal Aortic) Venous Duplex (Lower Extremity) Arterial Duplex (Lower Extremity) Renal Arterial Ultrasound

Clinical Context

Reason for Referral / Clinical Notes

Preferred Appointment Timing

Report Delivery

Send a copy of the report to my office email

Additional Notes or Alternate Report Email

Every study interpreted by Dr. Glenn Gandelman MD FACC — board-certified cardiologist, Fellow ACC, Yale/Cornell Clinical Instructor. Report delivered in 24–48 hours via HIPAA-compliant encrypted email.

Prefer a Referral Pad?

Keep a pad at your front desk. Your patient fills it out in the waiting room — you hand it to them, we handle the rest.

Download Referral Pad →

Urgent Referral?

For same-day or next-day appointments, call us directly.

(207) 409-7797

What Happens Next

01 We contact your patient within 1 business day

02 Scan performed at their chosen location

03 Report delivered to patient and your office in 24–48 hrs

Send a patientin under 2 minutes

Referral Received

Send a patient
in under 2 minutes