Meadowbrook Referral Form - Corbett Medical Services

PROF John Corbett & ASSOCIATES
MEADOWBROOK NEUROPHYSIOLOGY CLINIC
Dr Ventzi Bonev
Prof John Corbett
Consultant Neurologist & Sleep Physician
Consultant Neurologist
M.B., B.S. (Hons), F.R.C.P. (UK), F.R.A.C.P., M.A. (Oxford),
D.Phil.(Oxford), M.A.C.L.M.
M.D., FCNeur(SA), F.R.A.C.P.
REFERRAL FOR NEUROPHYSIOLOGY INVESTIGATION AND ASSOCIATED CONSULTATION
All Services Listed are Bulk Billed
Workcover or Insurance
Peripheral neurophysiological studies: Neurological consultation plus nerve
conduction studies / EMG (eg, for focal nerve entrapment, generalised peripheral
neuropathy and other neuro-muscular disorders. Note: Details of test protocol to be
decided by Prof Corbett or Dr Bonev following clinical assessment.
Brain studies: Electroencephalography (EEG), no consultation offered
(eg, for epilepsy, "fits, faints, & funny turns", in patients aged over12 years).
Standard EEG (45 min)
Provocation EEG with food & sleep deprivation (3hr+ with video monitoring,
unless alternative study type requested)
Please tick if patient is diabetic (so that food-deprivation can be avoided)
Ambulatory EEG (at home) 27hr
We accept referrals
via Medical Objects
Ambulatory EEG (at home) 51hr
Ambulatory EEG (at home) 75hr
Patient's Name..........................................................................................................
Patient's DOB...................................... Patient's Phone No.....................................
PATIENT'S MEDICARE No. (MUST BE ENTERED)
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Clinical Notes.......................................................................................................
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FAX
referral to
5503 2488
Referring Doctor.........................................................................
Referring Doctor's Provider No. .............................................
Our staff will
contact the patient
Referring Doctor's Address ...............................................
Bookings phone 5503 2499
Email [email protected]
Web www.corbett.com.au
80 Armstrong Road, Meadowbrook 4131
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Signature....................................................
Date.........................................
SUBMIT
Patient Information
Appointment: Date ............................................... Time ..................................
Please bring:
1. Referral letter from your doctor
2. Previous X-rays, CT scans, MRI scans, pathology results and a
list of your medications
3. Your MEDICARE card or your DVA Gold Card
4. Your completed questionnaire.
EEG Preparation:Wash your hair before coming to the surgery. Use soap or plain
shampoo. Do Not use conditioners, gels, sprays, etc.
Nerve Conduction Studies / EMG: No special preparation required.
TESTS AND ASSOCIATED CONSULTATION ARE BULK BILLED - YOU WILL NOT BE CHARGED AN OUT-OFPOCKET FEE. YOU ARE HOWEVER REQUIRED TO CONFIRM YOUR ATTENDANCE THE DAY BEFORE.
Location:
SNORE AUSTRALIA CLINIC, 80 Armstrong Road, Meadowbrook 4131
(Just past Logan Hospital and TAFE College).
Phone: 07 5503 2499
PUBLIC TRANSPORT: Walk from Loganlea Railway Station.
Driving Directions:
W
From Brisbane towards the Gold Coast on the M1:
S
TT
NE
IN
M1
Take the Winnets Rd / Loganlea Rd Exit 24, go up the hill
to the roundabout, turn right into Loganlea Rd and travel
along Loganlea Rd through 5 sets of lights.
RO
AD
IFIC
PAC
The Logan Hospital will be on your left, then follow the
signs to Armstrong Rd (before the overhead bridge);
go past the Hospital entrance and past the TAFE on
the left; SNORE AUSTRALIA clinic is 6 houses
AD
RO
down on the left.
LEA
AN
MO
R
TO
LO
G
Y
WA
PATIENTS
Please have your
MEDICARE card with
you if you phone for
your appointment
Phone: 07 5503 2499
LOGAN
HOSPITAL
LOGAN
TAFE
COLLEGE
EDENLEA DRIVE
SNORE
AUSTRALIA
CLINIC
ARMSTRONG ROAD
LO
TRA GAN
L
IN
STA EA
TIO
N
TRAIN LINE
PARK
LOGANLEA
HIGH SCHOOL