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:	<<Patient Demographics:Full Name>> Gender:  <<Patient Demographics:Sex>>	
  q	Specialist Clinic/DEM		D.O.B:	<<Patient Demographics:DOB>>UR:	
  x	Outpatient		Address:	<<Patient Demographics:Full Address>>	
		Medicare:  	<<Patient Demographics:Medicare Number>>	
		Ph: 		<<Patient Demographics:Phone (Home)>> (m): <<Patient Demographics:Phone (Mobile)>>	

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

Allergies: <<Clinical Details:Allergies>>	
	
Medications: <<Clinical Details:Medication List>>	
	
Clinical Notes: 

	

Requesting GP: <<Doctor:Name>>
Phone: <<Doctor:Phone>>  Fax: <<Doctor:Fax>>
Provider: <<Doctor:Provider Number>> 	If a requesting doctor is to also interpret results for an OROP, please complete the following:	
	Name of GP: 	
	Date of Referral:	
Signature:					Date: <<Miscellaneous:Date (short)>>