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www.southlandemg.com S

PleasefaxcompletedformtoSouthlandEMG,fax#(587)481-7877Version2.0,December2017

Referringphysician

Name:

Phone:Fax:

PRACID:

Name:Gender:

DateofBirth:ULI:

Address:

Phone:(H)(W)

PATIENT INFORMATION (can use label)

REFERRAL INFORMATION

ClinicalquestionCarpaltunnelsyndromeCervicalradiculopathyUlnarneuropathyLumbosacralradiculopathyPolyneuropathy PlexopathyIfother,pleasespecify:

Clinicalinformation(pleaseattachpreviousEMGstudies,consults,relevantimaging,bloodworkandmedications)

PastmedicalhistoryDiabetes HIVorHepatitisCThyroiddisease AlcoholabuseOther: Isthepatientonanticoagulation: Yes No

Priority:UrgentRoutine

UrgentrequestsmustbediscussedbydirectconsultationwithDr.Mrkobrada

Physician’ssignature: Date:

Dr. Serge Mrkobrada MD, MSc, FRCPC, CSCN Diplomate (EMG)

EMG Referral Form