Upload
vonguyet
View
225
Download
3
Embed Size (px)
Citation preview
10003-24thSt.SW,T2V5K3Tel:(587)481-7866Fax:(587)481-7877
www.southlandemg.com S
PleasefaxcompletedformtoSouthlandEMG,fax#(587)481-7877Version2.0,December2017
Referringphysician
Name:
Phone:Fax:
PRACID:
Name:Gender:
DateofBirth:ULI:
Address:
Phone:(H)(W)
PATIENT INFORMATION (can use label)
REFERRAL INFORMATION
ClinicalquestionCarpaltunnelsyndromeCervicalradiculopathyUlnarneuropathyLumbosacralradiculopathyPolyneuropathy PlexopathyIfother,pleasespecify:
Clinicalinformation(pleaseattachpreviousEMGstudies,consults,relevantimaging,bloodworkandmedications)
PastmedicalhistoryDiabetes HIVorHepatitisCThyroiddisease AlcoholabuseOther: Isthepatientonanticoagulation: Yes No
Priority:UrgentRoutine
UrgentrequestsmustbediscussedbydirectconsultationwithDr.Mrkobrada
Physician’ssignature: Date:
Dr. Serge Mrkobrada MD, MSc, FRCPC, CSCN Diplomate (EMG)
EMG Referral Form