PATIENT INFORMATION REFERRING PHYSICIAN Park Rowe Avenue Baton Rouge, LA 70810 Phone: 225.769.2200 T PHYSICIAN FAX REFERRAL REQUEST/ORDER FAX THIS REFERRAL TO APPOINTMENT SCHEDULING AT 225.768.2186

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<ul><li><p>10101 Park Rowe Avenue </p><p>Baton Rouge, LA 70810 </p><p>Phone: 225.769.2200 </p><p>TheNeuroMedicalCenter.com </p><p>PHYSICIAN FAX REFERRAL REQUEST/ORDER </p><p>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. </p><p>PATIENT INFORMATION (Please print) </p><p> Patients Name________________________________________________________________________________ D.O.B._______/_______/____________ Street Address___________________________________________________ City____________________________ State______ Zip_________________ Home Phone (______) _______________________ Cell Phone (______) _______________________ Work Phone (_______) _______________________ Diagnosis_______________________________________________________________________ Diagnosis Code_________________________________ Insurance Name_________________________________ Member #___________________________________ Group #____________________________ </p><p>*****Please attach a copy of the insurance card if possible.***** </p><p>REFERRING PHYSICIAN INFORMATION </p><p>MD Name (print)_____________________________________________________________________ Date______________________________________ Signature of Referring Physician__________________________________________________ Nurse/Contact_____________________________________ Phone (______)______________________ FAX (______) __________________________ Physicians Secure E-mail ______________________________ </p><p>SERVICES REQUESTED NEUROSURGERY - 3</p><p>RD FLOOR NEUROSURGERY (continued) PHYSICAL MEDICINE &amp; IMAGING SERVICES1</p><p>ST FLOOR </p><p> Charles R. Bowie, M.D. (Adults) Richard A. Stanger, M.D. (Adults) REHABILITATION/ (Please send previous records.) </p><p> Baton Rouge Baton Rouge PAIN MEDICINE 3RD</p><p> FLOOR MRI* MRA* X-Ray*</p><p> Eunice Covington Martin A. Langston, M.D.</p><p> Luke A. Corsten, M.D. (Adults) Walker John E. Nyboer, M.D.</p><p>DIAGNOSTIC SERVICES-4th</p><p> FLOOR </p><p> Baton Rouge Paul J. Waguespack, M.D (Adults) Scott D. Nyboer, M.D EEG </p><p> Gregory Fautheree, M.D. (Adults) Baton Rouge Samir K. Patel, M.D. EEG 24 Hour Ambulatory</p><p> Baton Rouge First Available Baton Rouge Carotid Ultrasound</p><p> Eunice Gonzales Transcranial Doppler </p><p> St. Francisville NEUROLOGY 4TH</p><p> FLOOR Walker EMG*</p><p> Allen S. Joseph, M.D. (Children) Gerald J. Calegan, II, M.D. Jyoti S. Pham, M.D. Nerve Conduction*</p><p> Baton Rouge Charles E. Eberly, M.D. First Available BAER</p><p> Horace L. Mitchell, M.D. (Adults) April A. Erwin, M.D. VER </p><p> Baton Rouge Dariusz W. Gawronski, M.D. OUTPATIENT THERAPY 4th</p><p> FLOOR SSEP/PT</p><p> Eric K. Oberlander, M.D. (Adults) B. Glenn Kidder, Jr., M.D. Physical Therapy SSEP/MN </p><p> Baton Rouge Jon D. Olson, M.D. Occupational Therapy *Please provide specifics in </p><p> Covington Darian E. Reddick, M.D. Hand Therapy Comments section </p><p> Hammond Mehdi Soltani, M.D. Dry Needling DURABLE MEDICAL </p><p> Kelly J. Scrantz, M.D. (Adults) Rebecca E. Whiddon, M.D. Kinesio Taping EQUIPMENT </p><p> Baton Rouge First Available Back Brace</p><p> Gonzales TENS unit</p><p> Scott W. Soleau, M.D. (Adults) NEUROPSYCHOLOGY-4TH</p><p> FLOOR Readi-Steadi Anti-Tremor</p><p> Baton Rouge John F. Bolter, Ph.D., M.P. Hand Orthotic </p><p> St. Francisville Jessica L. Brown, Ph.D., M.P. </p><p> Darla M.R. Burnett, Ph.D., M.P. Insurance Authorization # </p><p> Brooke B. Cole, Ph.D., M.P. __________________________ </p><p> Paul M. Dammers, Ph.D., M.P. Expiration Date: </p><p> First Available </p><p>Comments________________________________________________________________________________________________________________ MRI_________________________________________________________MRA________________________________________________________ X-Ray_______________________________________________________EMG/NCV____________________________________________________ </p><p>REVISED 04/2017 </p><p>FOR THE NEUROMEDICAL CENTER CLINIC TO COMPLETE Your patient is scheduled as follows: </p><p> Doctor/Test__________________________________ Date__________________ Time____________ Location___________________________ </p></li></ul>

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