COASTAL NEUROPHYSIOLOGY REFERRAL
Nerve Conduction Study / Electromyography (NCS/EMG) 

SEND TO Dr Ventzi Bonev (Consultant Neurologist)
Coastal Neurophysiology
8 Rawlins St, Southport 4215
Phone:  07 5503 2499
Fax:     07 5503 2488

Secure Transmission Service via Medical Objects:
Dr Ventzi Bonev	FROM <DrName>
<Practice>
<UsrAddress>
Phone: <UsrPhone>
Fax: <UsrFax>
Email: <DrEmail>
Provider Number: <DrProviderNo>	

<TodaysDate>

Dear Dr Bonev

Patient details

RE: <PtFullName>
DOB: <PtDoB>
AGE: <PtAge>

Gender: <PtSex>
Address: <PtAddress>
Home Ph: <PtPhoneH>
Mobile Ph: <PtPhoneMob>	Referral type: <Referral type>
Medicare Number: <PtMCNo>
DVA Number:<PtDVANo>	

Reason for NCS/EMG Referral

For NCS/EMG of possible: <For NCS/EMG of possible:>
<If focal neuropathy is suspected please specify:>
<If "other" please elaborate>
<If generalised neuropathy suspected is there history of:>
<If "other" please elaborate>
<If Radiculopathy/Plexopathy is suspected please localise:>
Please include any symptoms and date of onset (if known): <Symptoms and date of onset if known>
Paste or type relevant history, clinical examination findings and treatment to date if required
CC results to:<CC>

General information about Coastal Neurophysiology

All referrals are viewed and triaged upon receipt and neurophysiology reports are usually available within 24 hours.  If urgent study is required please indicate.  

Complex conditions may include a bulk-billed consultation if deemed clinically relevant by Dr Bonev (Item 110).

All patients will be required to complete a patient questionnaire prior to their appointment which is available at https://coastalneuro.com.au/for-patients/patient-questionnaire/

General patient information about Coastal Neurophysiology is available at https://www.coastalneuro.com.au