REFERRALS | EEG Services Australia

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Our Locations

GOLD COAST - PREMION PLACE
Suite 5, 39 White Street, Southport QLD 4215

BRISBANE - RIVER CITY HOSPITAL
Suite 1C Level 1, 401 Milton Road, Auchenflower, QLD 4066

SUNSHINE COAST - PULSE OCEANSIDE MEDICAL
Suite 401, 11 Eccles Boulevard, Birtinya QLD 4575

EEG Request Form

Select Location of EEG(Required)

Select Type of EEG(Required)

Ambulatory Overnight EEG(Required)

Overnight

1 Day

2 Days

3 Days

4 - 7 Days

Consultation with a Neurologist required?(Required)

Yes

No

Please Select Neurologist(Required)

Paediatric Neurologist - Dr Harry Singh (GC)

Paediatric Neurologist - Dr Yeeshu Singh Sudan (GC)

Adult Neurologist/Epileptologist - Dr Meng Tan (GC)

Paediatric Neurologist/Epileptologist - Dr Sameer Dal (BNE)

Adult Neurologist - Dr Warwick Rivlin (SC)

No Preference / Next Available

Patients Details

Patient First Name*(Required)

Patient Last Name*(Required)

Patient Email*(Required)

Patient Phone Number*(Required)

Patient Address*(Required)

Patients Age*(Required)

Date of Birth*(Required)

Parents Name*(Required)

Clinical History

History and Seizure/Clinical Event Details*(Required)

Please select any relevant conditions:

Asthma (Preventer meds required)

COPD/Other lung Condition

Cerebrovascular History (Stroke/TIA/Aneurysm/Cavernoma/AVM/Moya Moya)

Brain Insult/Known Brain Lesions

Previous Investigations

EEG

MRI

Medications

Referring Doctor Details

Doctor Name*(Required)

Provider Number*(Required)

Clinic Phone Number*(Required)

Doctor Clinic Address*(Required)

Doctor Email*(Required)

Referral Date*(Required)

Doctor's Signature(Required)

Please sign using your mouse or finger on touch screen devices. To redo or clear, please click on the refresh icon (bottom right corner of signature box).

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