Department of Cardiology & Neurology
Launceston General Hospital
Charles St Launceston 7250

Ph: 03 6777 6465  Fax: 03 6777 5199		
	
REQUEST for EEG		

Origin of Request			
  q	Inpatient-Ward___		Name:	<PtName>  Gender:  <PtSex>	
  q	Specialist Clinic/DEM		D.O.B:	<PtDoB>	UR:	
  x	Outpatient		Address:	<PtAddress>	
		Medicare:  	<PtMCNo>	
		Ph: 		<PtPhoneH>  (m): <PtPhoneMob>	

   q	Adult Neurologist	  q	Dr T Ware  (Paediatric EEG - Under 10yrs)	
 Test required:		
   q	Adult EEG	  q	Paediatric EEG	
	  q	Sleep Deprived EEG	

Allergies	<Reactions>	
	
Medications: <SelectedRx> 	
	
Clinical Notes: 

	

Requesting GP: <DrDetails>
Ph: <DrPhone>   Fax: <DrFax>
Provider: <DrProviderNo>	If a requesting doctor is to also interpret results for an OROP, please complete the following:	
	Name of GP: 	
	Date of Referral:	
Signature:						Date: <TodaysDate>