Download - NEUROLOGIST NEUROPHYSIOLOGY REQUEST FORMredlandsspecialistcentre.com.au/wp-content/uploads/20… · · 2017-10-29B.Sc., MBBS, MRCP (UK), FRACP NEUROLOGIST NEUROPHYSIOLOGY REQUEST

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