Online Referral Form

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DOCX Version

Patient Details

Patient's Name

Date of Birth

Address

Contact Number

Requesting Doctor Details

Doctor's Name

Practice Name

Provider Number

Contact Number

Specialist General Practitioner

*GP referrals accepted for adult EEG’s only

EEG Test type

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

Springwood Springfield Sunshine Coast Toowoomba Townsville 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?

Yes No

Have you discussed the risks and benefits of sleep deprivation with the patient, if requested?

Yes No

Signature:

Date

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If not, check all required fields are completed or email the printable form available on this page.

Contact

07 3186 6997
07 3186 6998

ABN: 70681619152

Precision EEG uses Medical Objects

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Quicklinks

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

We acknowledge the Traditional Custodians of the land on which we work and live, and recognise their continuing connection to land, waters and culture. We pay our respects to Elders past and present, and extend that respect to all Aboriginal and Torres Strait Islander peoples