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General Neurology
Referral Form
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BG Neurology Referral Form
1770 Skylyn Dr.
Spartanburg, SC, 29307
P: 864-577-9107 F: 864-699-1999
Referring Provider Name
Phone
Fax
NPI
PATIENT INFORMATION
Patient Name
INCLUDED(Required): all Name
Date of Birth
Gender
Male
Female
Phone
Email
*
Address
PATIENT INFORMATION
Primary Insurance
Member ID
Group
Secondary Insurance
Member ID
Group
REQUESTED SERVICES:
Consultation/treatment
EMG / NCS
EEG
CAR/TCD
Extremity
REASON FOR REFERRAL (Check all that apply):
Headache / Migraine
Seizures / Epilepsy
Neuropathy
Dizziness / Vertigo
Memory Loss / Cognitive Changes
Weakness / Numbness
Stroke / TIA Follow-up
Other
write other
PERTINENT RECORDS INCLUDED(Required):
*
Demographics
Ins info
Imaging
Imaging
Labs
Medication List
REFERRING PROVIDER SIGNATURE:
Provider Signature
Clear Signature
Date
Submit
