Child Neurology Clinic Consult Form by oqp13905


									                            Child Neurology Clinic Consult Form

Patient Information

Patient Name (Last) ____________________________ (First) ___________________________

Date of Birth: _____________________________                      Female    Male 

Legal Guardian Name: _______________________________________

Relationship to Patient: _________________________________________

Phones (day):________________________ (evening) ______________________________


E-mail address: ______________________________

Home address: ________________________________________________________________

Insurance Plan: __________________________
Insured ID#_____________________________ Medical Group _________________________
Authorization#__________________________ Auth expire date ________________________

English Speaking? Yes  No If not, is an interpreter needed? What language?

Referring MD/NP:______________________________________________________________
We do not accept referrals from any emergency room physicians to our outpatient clinic.

MD Phone: __________________________________         Are you the PCP? Yes            No 

Reason for Visit
     Autism                             Seizures
     Cerebral Palsy                     Movement Disorders
     Developmental Delay                Neuromuscular Disorders/ Muscle Disease
     Headaches                          Tics

      Epilepsy
      Other, please describe_____________________________________________________

How long has this been going on?
      Days
      Weeks
      Months
      Years
What tests have been done?

      Brain MRI
      Head CT
      EEG
      Other:_____________________________________
Type of Visit
      New Problem

      Chronic Problem
      Second Opinion
      Transfer of Care from other Neurologist
      Other, please specify_______________________________________________________
      Urgent? Why?___________________________________________________________

Scheduled by:  first available or  preferred LPCH neurologist (specify): ________________

Please fax any pertinent clinical information with this form to the Referral
Center at 650-721-2884. If you have questions call 1-800-995-5724.
 The Neurology Clinic new patient scheduler will call your patient within one
week of receiving this form to schedule their appointment. Your patient
should bring all MRI/CT scans of the brain and spine with them to their clinic

Completed by________________________________ Date________________ Pg 2

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