*Please fax any office notes and labs done in the past 6 months along with referral ... us immediately by telephone and
NeuroScience Center Fax Referral Form Stroke Center Concussion Clinic Memory Disorder Clinic Parkinson’s Clinic Multiple Sclerosis Clinic
1401 Centerville Rd. Suite 504 Tallahassee, FL 32308 (850) 431 – 5037 p (850) 431 – 6101 / (850) 431 – 6421 f Dr. Siddharth Schgal, Vascular Neurology Dr. Heather Bradley, Neuropsychology
Patient Name: ____________________________ Date of Birth: ____________ Phone #: __________________ Date: __________________ ICD9 Code: __________________ Medical Diagnosis: __________________ Health Insurance: ____________________________ Group / ID #: ____________________________________ If not a PCP referral, who is PCP: ________________________________________________________________ *Please fax any office notes and labs done in the past 6 months along with referral form (e.g., MRI / CT Scan Reports, Labs)*
Stroke Clinic Concussion Clinic - Neuropsych, PT, OT, and ST evaluation Parkinson’s Center and Education - Neuropsych, PT, OT, and ST evaluation Multiple Sclerosis Center & Education - Neuropsych, PT, OT, and ST evaluation
EEG Pharmacy Consultation Social Work Consultation Research Candidate
Other ________________________________________________________ Health Care Provider’s Name (PLEASE PRINT): ____________________________________ Health Care Provider’s Signature: ________________________________________________ The information contained in this fax message is intended only for the personal and confidential use of the designated recipient(s) named above. This message may be an attorney-client or physician-patient communication and as such is privileged and confidential. If the reader of this message is not the intended recipient or an agent responsible for delivering it to the intended recipient you are hereby notified that you have received this document in error, and that any review,
dissemination, distribution, or copying of this message is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone and return the original message to us by mail. Thank you!
