For Referring Doctors

EEG and Ambulatory EEG Referral

Request EEG and Ambulatory EEG testing for your patients. We aim to provide prompt appointments based on clinical need.

Referral Requirements

A valid referral from a GP or specialist is required for Medicare rebates. Please include relevant clinical history and any previous investigation results.

Call Us Email Referral

Patient Information

Details of the patient being referred

First Name *

Last Name *

Date of Birth *

Gender *

Phone Number *

Email Address

Address

Medicare Number

Medicare Reference No.

Special Requirements

Interpreter Required

Patient requires language assistance

Mobility Assistance

Wheelchair or mobility support needed

If interpreter required, specify language

Referring Doctor Information

Your details for the referral

Doctor's Name *

Provider Number *

Practice Name *

Practice Phone *

Fax Number

Email Address *

Send copy of results to referring doctor

We'll email the report when available

Tests Requested

Select the required investigations

EEG Studies *

Routine EEG (30 minutes) Sleep Deprived EEG (60 minutes) Prolonged EEG (60 minutes) Home-based Ambulatory EEG

Clinical Information

Relevant history and reason for referral

Reason for Referral / Clinical Question *

Relevant Clinical History *

Current Medications

Previous Investigations

Attach Referral Letter or Reports (Optional)

Click to upload or drag and drop

PDF, DOC, DOCX, JPG or PNG (max 10MB)

Additional Notes or Special Instructions

By submitting this form, you confirm the information provided is accurate and you have obtained appropriate consent from the patient.

Prefer to Send a Traditional Referral?

You can also send referrals via fax or email

Phone

07 3130 5909

Email

reception@rivercityneurology.com.au

Fax

07 3130 5910