Malvern Neurology – Patient Information Sheet Please fill in and submit with your referral Doctor's NameSelect doctor you are being referred toProfessor Owen WhiteDr Luke ChenDr John WaterstonDr Judith FrayneDr Ron FreilichDr Jorge ZavalaDr Wai Foong HooiDr Anita VintonDr Rubina AlpitsisA/Prof Wesley ThevathasanProfessor Patrick KwanDr Chris DwyerProf Bruce CampbellDr Kar Yan LoDr Suba RaviskanthanDr Vimal StanislausDr Hannah RosenfeldDr Paul KopanidisTesting Referrals Only (NCS, EMG, EEG OCT, VF)First Available – with any doctorMr/Mrs/Ms/Miss/Other*Surname*Given Names*Address:Street*Suburb*Postcode*Telephone:Home*WorkMobile*Date of Birth:* MM slash DD slash YYYY Age*OccupationNext of kin:Name*Address*TelephoneReferring DoctorAddressTelephoneName of GP (if different): AddressNames of other doctorsPrivate insurance* Yes No Name of CompanyMembership NoMedicare NoRef NoExpiry DateDVA NoPension (Full or Part)Pension NoHCC NoWorkcover/TAC DetailsEmployerAddressInsurance CoAddressClaim NoDate of Injury MM slash DD slash YYYY Medical HistoryNeuropathy* Yes No Multiple Sclerosis* Yes No Parkinsons Disease* Yes No Asthma* Yes No Heart Disease/Angina* Yes No Peptic ulcer disease/Reflux* Yes No Cholesterol/Triglycerides* Yes No Diabetes* Yes No Hypertension* Yes No Glaucoma* Yes No Thyroid Disease* Yes No Stroke/TIA* Yes No Epilepsy* Yes No Other problems* Yes No Allergies* Yes No MedicationsNameDoseFrequencyNameThis field is for validation purposes and should be left unchanged.
