Nerve Conduction Studies
Testing Request Form
Clinical Investigations Unit
Sunshine Coast University Hospital

	Date of referral: <TodaysDate>

Re: <PtFirstName> <PtSurname>
Address: <PtAddress>
DOB: <PtDoB>
Sex: <PtSex>
Home phone: <PtPhoneH>
Mobile phone: <PtPhoneMob>
Medicare Number: <PtMCNo>
DVA Number: <PtDVANo>	
Use this form for requesting Nerve Conduction Studies TESTING ONLY.
If a clinical consultation is required a separate referral is required.	
Referral to:	<Specialist referred to?>	
Transport:	<Transport?>	
Clinical question to be answered by NCS/EMG
<Clinical question to be answered by NCS/EMG>
<Other clinical question to be answered by NCS/EMG>	
Clinical Details:
<Other clinical details>	
Relevant Medical History:
<Relevant medical history>
<Other relevant medical history (please specify)>	
Current Medication:
<Anticoagulant> Anti-Coagulant          <Statins> Statin               <Antiplatelets> Antiplatelets

List other medication names and dosage:
<SelectedRx>	
Allergies:
<Reactions>	
Intellectual/Physical/Other disabilities which may affect ability to comply with test:
<Intellectual/Physical/Other disabilities which may affect ability to comply with test>
<Other disabilites which may affect ability to comply with test>	
Has a separate SCUH neurology consult been requested? <Has a separate SCUH neurology consult been requested?>	
Requested by: <DrName>	Provider No.: <DrProviderNo>	
Phone: <DrPhone>	Fax: <DrFax>	
OFFICE USE ONLY		
Date of test: 	Time of Test:	
c Cat 1	c Cat 2	c Cat 3	c 30 min	c 45 min	c 60 min	

Secure electronic transfer to: (NQ45600007J)
If unable to send electronically, fax to (07) 5202 0555
Specialty referred to: Clinical Investigation Unit