Dubbo Hospital Ambulatory Care
For bookings 
Phone: 02 6809 7405
Fax: 02 6809 7441
Argus: wnswlhd-ccdubsmc@health.nsw.gov.au
		
Patient Details 
Name: <PtName>	DOB: <PtDoB>	
Address: 
<PtAddress>	Phone: <PtPhoneH>
Mobile:  <PtPhoneMob>	
Medicare Card: <PtMCNo>	Ethnicity: <PtEthnicity>	
DVA Card: <PtDVANo>		

Clinical Questions: 

	

Nerve condition studies and Electromyography:    
       <Nerve condition studies and Electromyography?>   	
Is the patient taking an anticoagulant?     <Is the patient taking an anticoagulant?>  	
Pacemaker or implanted electrical device?    <Pacemaker or implanted electrical device?>	

EEG unavailable until further notice

Referring Clinical Details
Name: <DrName>	Provider Number: <DrProviderNo>	
Practice Address: <UsrAddress>	Copy to: <Copy to?>	
Practice Phone: <UsrPhone>	Practice Fax: <UsrFax> 	

Signature:	
Date: <FormattedDate>	
	                                       
Dubbo inpatient studies: Please Argus or fax to 6809 7441, discuss with Neurologist to arrange a time, and ensure a contact number (pager or mobile) is listed above for the team JMO.

Age Limits: NCS/EMG: Age 16 and over, EEG: Age 2 and over. Please discuss with Dr Crossley if there is a strong clinical need for testing outside those age ranges. Please note single fibre EMG and evoked potential testing is unavailable currently.