10101 Park Rowe Avenue
Baton Rouge, LA 70810
Phone: 225.769.2200
TheNeuroMedicalCenter.com
PHYSICIAN FAX REFERRAL REQUEST/ORDER
FAX THIS REFERRAL TO APPOINTMENT SCHEDULING AT 225.768.2186. We will call your patient and schedule an appointment. Thank you for your referral. If you have any other questions, call Scheduling at 225.768.2050.
PATIENT INFORMATION (Please print)
Patient’s Name________________________________________________________________________________ D.O.B._______/_______/____________ Street Address___________________________________________________ City____________________________ State______ Zip_________________ Home Phone (______) _______________________ Cell Phone (______) _______________________ Work Phone (_______) _______________________ Diagnosis_______________________________________________________________________ Diagnosis Code_________________________________ Insurance Name_________________________________ Member #___________________________________ Group #____________________________
*****Please attach a copy of the insurance card if possible.*****
REFERRING PHYSICIAN INFORMATION
MD Name (print)_____________________________________________________________________ Date______________________________________ Signature of Referring Physician__________________________________________________ Nurse/Contact_____________________________________ Phone (______)______________________ FAX (______) __________________________ Physician’s Secure E-mail ______________________________
SERVICES REQUESTED NEUROSURGERY - 3
RD FLOOR NEUROSURGERY (continued) PHYSICAL MEDICINE & IMAGING SERVICES–1
ST FLOOR
Charles R. Bowie, M.D. (Adults) Richard A. Stanger, M.D. (Adults) REHABILITATION/ (Please send previous records.)
Baton Rouge Baton Rouge PAIN MEDICINE – 3RD
FLOOR MRI* MRA* X-Ray*
Eunice Covington Martin A. Langston, M.D.
Luke A. Corsten, M.D. (Adults) Walker John E. Nyboer, M.D.
DIAGNOSTIC SERVICES-4th
FLOOR
Baton Rouge Paul J. Waguespack, M.D (Adults) Scott D. Nyboer, M.D EEG
Gregory Fautheree, M.D. (Adults) Baton Rouge Samir K. Patel, M.D. EEG – 24 Hour Ambulatory
Baton Rouge First Available Baton Rouge Carotid Ultrasound
Eunice Gonzales Transcranial Doppler
St. Francisville NEUROLOGY – 4TH
FLOOR Walker EMG*
Allen S. Joseph, M.D. (Children) Gerald J. Calegan, II, M.D. Jyoti S. Pham, M.D. Nerve Conduction*
Baton Rouge Charles E. Eberly, M.D. First Available BAER
Horace L. Mitchell, M.D. (Adults) April A. Erwin, M.D. VER
Baton Rouge Dariusz W. Gawronski, M.D. OUTPATIENT THERAPY – 4th
FLOOR SSEP/PT
Eric K. Oberlander, M.D. (Adults) B. Glenn Kidder, Jr., M.D. Physical Therapy SSEP/MN
Baton Rouge Jon D. Olson, M.D. Occupational Therapy *Please provide specifics in
Covington Darian E. Reddick, M.D. Hand Therapy Comments section
Hammond Mehdi Soltani, M.D. Dry Needling DURABLE MEDICAL
Kelly J. Scrantz, M.D. (Adults) Rebecca E. Whiddon, M.D. Kinesio Taping EQUIPMENT
Baton Rouge First Available Back Brace
Gonzales TENS unit
Scott W. Soleau, M.D. (Adults) NEUROPSYCHOLOGY-4TH
FLOOR Readi-Steadi Anti-Tremor
Baton Rouge John F. Bolter, Ph.D., M.P. Hand Orthotic
St. Francisville Jessica L. Brown, Ph.D., M.P.
Darla M.R. Burnett, Ph.D., M.P. Insurance Authorization #
Brooke B. Cole, Ph.D., M.P. __________________________
Paul M. Dammers, Ph.D., M.P. Expiration Date:
First Available
Comments________________________________________________________________________________________________________________ MRI_________________________________________________________MRA________________________________________________________ X-Ray_______________________________________________________EMG/NCV____________________________________________________
REVISED 04/2017
FOR THE NEUROMEDICAL CENTER CLINIC TO COMPLETE Your patient is scheduled as follows:
Doctor/Test__________________________________ Date__________________ Time____________ Location___________________________
