Launceston Health Hub,
 Level 1, 247 Wellington St
Launceston TAS 7250
Ph:   03 6388 8115    Fax: 03 6388 8114

EEG REQUEST	

Our preference is ereferral via our Healthlink EDI  lmc32lmc
	
Name:	<PtName> Gender:  <PtSex>	
D.O.B:	<PtDoB>	
Address:	<PtAddress>	
Medicare:  	<PtMCNo>	
Ph: 		<PtPhoneH> (m): <PtPhoneMob>	

 Test required:		
   	q	Adult EEG (10yrs+)		
	q	Sleep Deprived EEG		  	

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

	

Requesting GP:   <DrName>		Provider No: <DrProviderNo>

<Practice>, <DrStreet>  <DrCity>  <DrPostcode>

Ph: <DrPhone>  Fax: <DrFax>

Signature:									Date: <TodaysDate>