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Who We Are
EEG Services
In-Clinic
In-Home
Patients
Patient Information
In-Home Equipment
Physicians
Contact & Locations
Who We Are
EEG Services
In-Clinic
In-Home
Patients
Patient Information
In-Home Equipment
Physicians
Contact & Locations
Who We Are
EEG Services
In-Clinic
In-Home
Patients
Patient Information
In-Home Equipment
Physicians
Contact & Locations
Refer to us
Referral Forms
Online Referral Form
PDF Version
DOCX Version
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Patient Details
Patient's Name
Date of Birth
Address
Contact Number
Email
Requesting Doctor Details
Doctor's Name
Practice Name
Provider Number
Contact Number
Email
Specialist
General Practitioner
*GP referrals accepted for adult EEG’s only
EEG Testing
In-Clinic
Routine
Nap<3 years old
Sleep Deprived
In-Home
In-Home Ambulatory EEG Monitoring (No Video) 1 night
In-Home Video EEG Monitoring 2 nights
In-Home Video EEG Monitoring 4 nights
In-Home Video EEG Monitoring 6 nights
Number of nights (2-7):
Preferred Clinic Location
Norman Park
Springwood
Springfield
Sunshine Coast
Next Available
Reason for Referral
Past Medical History (including cerebrovascular, brain conditions, cardiac or pulmonary disease)
ASD Level 2/3 or significant anxiety
Yes
No
Current Medications
Previous Investigations (EEG, MRI)
Referral Disclosures
To access MBS Items, click here:
11000
(in-clinic),
11004
and
11005
(in-home)
Does the indication for the EEG fulfill the relevant Medicare requirement listed above?
Have you discussed the risks and benefits of sleep deprivation with the patient, if requested?
Signature:
Date
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