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) ____ _____ _ Clinical Notes....................................................................................................... .......................................................................................................................... ..................................................................................................................... ............................................................................................................... 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 ................................................................................ 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