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Referral Form
Neurophysiology and Botulimun Toxin Treatment Referral Pad
Patient name
DOB
Address
Contact Number
Test Requested
Consultation
NCS/EMG
Upper Limbs
Carpal Tunnel Syndrome
Wrist Drop
Myopathy
Ulnar Neuropathy
Brachial Plexopathy/radiculopathy
Lower Limbs
Foot drop
Femoral Neruopathy
Muopathy
Lumbo-sacral plexo/radiculopathy
Peripheral neruopathy
Other
EEG
Routine
Sleep Deprived
Somato Sensory Evoked Potential (SSEP)
Upper Limbs
Lower Limbs
Dermatomal (e.g. for Meralgia Paraesthetica)
Visual Evoked Potential
Bptulinum Toxin
Ch Migraine
Blepharospasms
Limb Spasticity
Cervical Dystonia
Hemifacial Spasms
Axillary hyperhidrosis
Other
Referring Doctor
Provider No.
Address
Phone
Fax
EEG
No fasting is required
Take regular medications as prescribed
Wash hair the night before test
Do not use hairspray, mousse, oils etc after washing hair
VEP
Wash hair and keep dry, night before test
Prescription spectacles (if relevant)
NCS/EMG/SSEP
No cream on upper and loewr limbs
Loose fitting clothing
Bring your list of medications
Sleep-deprived EGG Instructions
17 years and over - Stay awake from 3AM and no caffiene or energy drink 24 hours prior
All prescribed medications to be taken as usual
Breakfast as usual
Parking
Email address
