FAX  REFERRAL REQUEST

2335 E. Kashian Lane, Suite 260 · Fresno, CA 93701	 Phone: 559.256.5130 · Fax: 559.485.4504
UniversityMDs.com
Referrals can be made by faxing this form or calling the office.
Date: 	Number of Pages:  	

Vijay Balasubramanian, MD
Pulmonary Hypertension
Kathryn Bilello, MD
Timothy Evans, MD, PhD
Anil Ghimire, MD
Pravachan V C Hegde, MD
Interventional Pulmonology

Vipul Jain, MD

PFT TESTING ONLY
Full PFT (Spiro pre/post, lung volume DLCO)
6 min walk test
with O2 titration
Spirometry
with Bronchodilator
Lung Volumes
Other 	

Jose Joseph-Vempilly, MD
Michael Peterson, MD
Daya Upadhyay, MD

First Available Physician

Referring Physician: 	Phone:	 PCP (if different from referring): 	Phone:	 Patient Name: 	DOB:	 Consultation For:  		 Diagnosis:  		

REQUIRED PATIENT INFORMATION
Copy of Referral
Copy of Insurance Card/Demo Sheet
Last Chart Notes
Lab Results
X-ray/Ultrasound report
Films requested from:  	 for delivery to: University Pulmonary Associates, 2335 E. Kashian Lane, Suite 260, Fresno, CA 93701
*****NOTE: All information is needed to schedule an appointment.
Special Instructions:  	

Contact person: 		Title:	 Phone: 	Fax:  		
Thank you very much for referring your patient to our office!
Internal Use Only
Appointment Date: 	Time: 	Contact Person:  	

Updated: June 2019