EAMC Neurosurgery Referral

Important Reminder to All Referring Services

We strongly encourage the inclusion of relevant imaging studies with your referral. This provides the reviewing consultant with the necessary clinical context.

Thank you.

Patient Information

Last Name *

First Name *

Middle Name

Name Suffix

Age *

Sex *

Date of Birth *

Hospital Number *

Date of Admission *

Referral Details

Classification *

Consultant *

Referring Service *

Referral Type *

Ward *

Room / Bed

Clinical Information

Reason for Referral *

Clinical Impression *

Brief History *

Glasgow Coma Scale (GCS) *

GCS E V M

Pertinent Physical Examination *

Referring Physician Information

Physician Name *

Email Address *

Attachments (Optional)

Upload Files (Images, Videos, PDFs, ZIP files)

Drag & Drop files here

or click to browse files

Accepted formats: Images (JPG, PNG, GIF), Videos (MP4, AVI, MOV), Documents (PDF), Archives (ZIP, RAR)