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 (if known)

Hospital Number *

Date of Admission *

Referral Details

Classification *

Refer to NSS Consultant: *

Referring Service *

Referral Type *

Attending Physician * The patient's attending physician of record.

Ward *

Room / Bed

Reason for Referral *

Clinical Information

Clinical Impression *

Chief Complaint *

Brief History *

Glasgow Coma Scale (GCS) *

GCS E V M

Pertinent Physical Examination *

Referral Uploaded by:

Physician Name *

Email Address *

Attachments (Optional)

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