NCS / EMG / EEG REQUEST FORM

REFERRING DOCTOR:

Name: 
Address: 
Phone: 
Facsimile: 

PATIENT DETAILS:

Name:Patient Demographics.Full Name
Date of Birth:Patient Demographics.DOB
Address:Patient Demographics.Full Address
Phone (H):Patient Demographics.Phone (Home)
PLEASE TICK APPROPRIATE BOX BELOW FOR THE TEST REQUIRED:

EMG / NCS – Electromyography / 
Nerve Conduction Study

Simple:
 Carpal Tunnel Syndrome
Complex:
Ulnar Neuropathy
Peripheral Neuropathy
Radiculopathy
Radial Neuropathy
Myopathy/Mysathenia Gravis
Other
	
	EEG - Electroencephalography

Routine EEG (1 hour)

Sleep Deprived EEG (1.5 hours)

Prolonged Video EEG (3 hours)	
CLINICAL DETAILS: 

	
MEDICATIONS:	
Anticoagulation:	Yes	No	
NEUROLOGICAL CONSULTATION NEEDED?	Yes	No	
REFERRING DOCTOR’S SIGNATURE: 

	DATE:

Miscellaneous.Date	
TO SCHEDULE AN APPOINTMENT PLEASE FAX REQUEST FORM TO (03) 9379 4115 OR PHONE: (03) 9379 4545	
PATIENT INSTRUCTIONS (EEG): Wash your hair the night before or morning of your appointment. Hair should be dry and free of products including gels, hairspray, leave-in-condition, mousse etc. Do not drink tea, coffee or fizzy drinks before the appointment. (EMG/NCS): Shower and keep your skin clear from any fragrances, moisturisers and creams. Wear comfortable, loose fitting clothing to your appointment	
Office Use Only**
Appointment Booked for:                                                                                                                                             at:	
 (MOB):Patient Demographics.Phone (Mobile)