2000SouthlandDriveSWTel:(587)481-7866Fax:(587)481-7877

www.southlandemg.com S

PleasefaxcompletedformtoSouthlandEMG,fax#(587)481-7877

Referringphysician

Name:

Phone:Fax:

PRACID:

Name:Gender:

DateofBirth:ULI:

Address:

Phone:(H)(W)

PATIENT INFORMATION (can use label)

REFERRAL INFORMATION

ClinicalquestionCarpaltunnelsyndromeCervicalradiculopathyUlnarneuropathyLumbosacralradiculopathyPolyneuropathy PlexopathyIfother,pleasespecify:

Clinicalinformation(pleaseattachpreviousEMGstudies,consults,relevantimaging,bloodworkandmedications)

PastmedicalhistoryDiabetes HIVorHepatitisCThyroiddisease AlcoholabuseOther: Isthepatientonanticoagulation: Yes No

Priority:UrgentRoutine

Physician’ssignature: Date:

Dr. Serge Mrkobrada MD, MSc, FRCPC, CSCN Diplomate (EMG)

EMG Referral Form