Dubbo Hospital Ambulatory Care
For bookings 
Phone: 02 6809 7405
Fax: 02 6809 7441
Argus: wnswlhd-ccdubsmc@health.nsw.gov.au
		
Patient Details 
Name: <<Patient Demographics:Full Name>>	DOB: <<Patient Demographics:DOB>>	
Address: 
<<Patient Demographics:Full Address>>	Phone: <<Patient Demographics:Phone (Home)>>
Mobile:  <<Patient Demographics:Phone (Mobile)>>	
Medicare Card: <<Patient Demographics:Medicare Number>>	Ethnicity: <<Patient Demographics:Ethnicity>>	
DVA Card: <<Patient Demographics:DVA Number>>		

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: <<Doctor:Name>>	Provider Number: <<Doctor:Provider Number>>	
Practice Address: <<Practice:Address>>	Copy to: <<Copy to?>>	
Practice Phone: <<Practice:Phone>>	Practice Fax: <<Practice:Fax>> 	

Signature:	
Date: <<Miscellaneous:Date>>	
	                                       
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.