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NeuroDiagnostic Unit
Level 3
Box Hill Hospital
Nelson Road, Box Hill, Vic 3128
Tel: (03) 9895 4639
Fax: (03) 9895 4610
 
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Patient Details (or patient label)DOB _________________
Surname _________________________ Given Names _________________
Address _________________________________________________________
________________________Postcode ___________ Tel _________________
Line

Clinical Details

 
 
Request for:

 

 
EEG   Referring Doctor MUST complete this section
Routine EEG Tickbox
Is patient on Warfarin/anticoagulant?
Tickbox Yes
Tickbox No
Does patient have a pacemaker?
Tickbox Yes
Tickbox No
  Sleep Deprivation EEG Tickbox
Line Referring Doctor
Electrophysiology   Name __________________________________________________________
  Routine nerve conduction studies/EMG Tickbox Address ________________________________________________________
  Visual evoked responses Tickbox ________________________________________________________________
  Brainstem auditory evoked responses Tickbox Tel __________________ Fax ________________ Provider No. __________
  Sensory evoked potentials Tickbox Signed __________________________________ Date__________________  

Map to NeuroDiagnostics