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Greenslopes Neuro Greenslopes Private Hospital Greenslopes QLD 4120 Tell: 07 3847 4366
Redlands Specialist Centre 119/16 Weipin Street
Cleveland QLD 4163 Tel: 3193 5413
www.qneurology.com.au
DR NABEEL SHE IKH B .Sc . , MBBS, MRCP , FRACP
NEUROLOG IST
NEUROPHYSIOLOGY REQUEST FORM Pleasesendallreferralsto
Fax:0730366545Email:[email protected]
PatientName: DateofBirth: Address: ContactTel: Studyrequired:
Briefclinicalhistory:Clinicalquestion:Referrerdetails
Name: Providernumber: Address: Tel: Fax:
£ NCS £ EMG £ Consultationrequired
