NEUROLOGIST NEUROPHYSIOLOGY REQUEST FORMredlandsspecialistcentre.com.au/wp-content/uploads/20… ·...
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Greenslopes Neuro Greenslopes Private Hospital Greenslopes QLD 4120 Tel: 07 3847 4366 Provider No 279109NK Redlands Specialist Centre 19/16 Weippin Street Cleveland QLD 4163 Tel: 07 3193 5413 Provider No 279109PY www.qneurology.com.au [email protected] Fax: 07 3036 6545 DR NABEEL SHEIKH B.Sc., MBBS, MRCP (UK), FRACP NEUROLOGIST NEUROPHYSIOLOGY REQUEST FORM Please send all referrals to Fax: 07 3036 6545 Email: [email protected] Patient Name: Date of Birth: Address: Contact Tel: Study required: Brief clinical history: Clinical question: Referrer details Name: Provider number: Address: Tel: Fax: £ NCS £ EMG £ Consultation required
Transcript of NEUROLOGIST NEUROPHYSIOLOGY REQUEST FORMredlandsspecialistcentre.com.au/wp-content/uploads/20… ·...
Greenslopes Neuro Greenslopes Private Hospital Greenslopes QLD 4120 Tell: 07 3847 4366 Provider No 279109NK
Redlands Specialist Centre 19/16 Weippin Street Cleveland QLD 4163
Tel: 07 3193 5413 Provider No 279109PY
www.qneurology.com.au [email protected]
Fax: 07 3036 6545
DR NABE E L SHE I KH B .Sc . , MBBS, MRCP (UK ) , FRACP
NEUROLOG IST
NEUROPHYSIOLOGY REQUEST FORM
P lease send a l l re fe r ra l s t o Fax : 07 3036 6545
Ema i l : admin@qneuro logy .com.au
PatientName: DateofBirth: Address: ContactTel: Studyrequired:
Briefclinicalhistory:Clinicalquestion:Referrerdetails
Name: Providernumber: Address: Tel: Fax:
£ NCS £ EMG £ Consultationrequired
