EEG Referral

Please complete and submit the below form.

EEG Referral

Use this form for requesting EEG TESTING ONLY.
If a clinical consultation is required, a separate referral is required.

Date Of Referral

Patient Name

Patients Mobile Phone

Patients Date of Birth

Sex

Male

Female

Patients Medicare Number

Ref Number:

Referral For

Clinical Details

include type of epilepsy, previous brain insult, side of lesion, drugs, alcohol, and previous medical history

Relevant Medical History

Allergies

Date Of Last Episode

Current Medications

Intellectual/Physical/Other disabilities which may affect ability to comply with test

Please ensure the following details are completed & SIGNED

Requested by

Provider No.

Practice Name

Phone

Address

Referring Dr Signature

If you are human, leave this field blank.