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Greenslopes Neuro Greenslopes Private Hospital Greenslopes QLD 4120 Tel: 07 3847 4366 Redlands Specialist Centre 119/16 Weipin Street Cleveland QLD 4163 Tel: 3193 5413 www.qneurology.com.au DR NABEEL SHEIKH B.Sc., MBBS, MRCP, FRACP NEUROLOGIST NEUROPHYSIOLOGY REQUEST FORM Please send all referrals to Fax: 07 3036 6545 Email: [email protected] Patient Name: Date of Birth: Address: Contact Tel: Study required: Brief clinical history: Clinical question: Referrer details Name: Provider number: Address: Tel: Fax: £ NCS £ EMG £ Consultation required

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Page 1: NEUROPHYSIOLOGY REQUEST FORM - Q Neurologyqneurology.com.au/wp-content/uploads/2016/12/NCS-R… ·  · 2016-12-03B.Sc., MBBS, MRCP, FRACP NEUROLOGIST NEUROPHYSIOLOGY REQUEST FORM

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

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NEUROLOGIST NEUROPHYSIOLOGY REQUEST FORMredlandsspecialistcentre.com.au/wp-content/uploads/20… ·  · 2017-10-29B.Sc., MBBS, MRCP (UK), FRACP NEUROLOGIST NEUROPHYSIOLOGY REQUEST

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