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:	<<Patient Demographics:Full Name>> Gender:  <<Patient Demographics:Sex>>	
D.O.B:	<<Patient Demographics:DOB>>	
Address:	<<Patient Demographics:Full Address>>	
Medicare:  	<<Patient Demographics:Medicare Number>>	
Ph: 		<<Patient Demographics:Phone (Home)>> (m): <<Patient Demographics:Phone (Mobile)>>	

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

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

	

Requesting GP:   <<Doctor:Name>>		Provider No: <<Doctor:Provider Number>>

<<Practice:Name>>, <<Doctor:Address>>  <<Doctor:City>>  <<Doctor:Postcode>>

Ph: <<Doctor:Phone>>  Fax: <<Doctor:Fax>>

Signature:									Date: <<Miscellaneous:Date (short)>>