Request For Outpatient Consultation
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1Name: Last_______________________________________________
UCLA Department of Neurology
Patient
First ___________________________________
(Please Print)
Request for Outpatient
Information
UCLA Registration# _______________________________ DOB:
Consultation
_______________________
Phone: (310) 794-1195
(UCLA Referring-please
Cell (_____) ________________
place label here)
Fax: (310) 794-7491
Address: ____________________________________
To be completed by
City:________________________ State:_________ Zip: _____
physicians/clinic staff
General Neurology
(Standard neurologic care for all conditions),
Subspecialty Clinic:
or
To
Ataxia
Headache
Neurobehavior
Dementia
Epilepsy
Neuro Oncology
Sleep
Stroke
Multiple Sclerosis
Autonomic disorders
Neuro Otology
Huntington’s Disease
Neuroinfectious Disease/NeuroAIDS
Neuro-Rehabilitation
Movement Disorder
Neuromuscular:
ALS & other motor neuron diseases
Adult neuromuscular disease
Pediatric neuromuscular diseases
or
Neurologist’s Name _________________________________________________________________
NOTE:
If the requested neurologist is unavailable, the patient will be seen by an alternative neurologist from the same subspecialty
program. If you would prefer that no appointment be made if the requested neurologist is unavailable, please check here
Reason For Consultation:
Reason
for
Presumptive Diagnosis: _________________________________________________________
Consult
and
Second Opinion?
YES
NO
Urgency
Appointment Requested:
Next Available
Within 2 weeks
Within 1 week
Other ________
If patient needs to be seen sooner than next available appointment, please indicate why:_______________________________
If specific studies are available please indicate below and request patient to hand deliver films/outside tests/notes :
MRI
CT
EEG
EMG/NCV
Sleep Study
Clinic Notes
Other__________
Referring Physician:______________________________________________ Office Name:_______________________
From
Last
(Please Print)
First
Office Contact:__________________________________________ Phone# (______) :__________________________
Fax#: (____) ___________________________________ E-Mail Address: _______________________________________
PCP
Physician Name:_________________________________________ Office Name:________________________________
(If different
Last
(Please Print)
First
from
Office Contact:_________________________________________________ Phone# (_____) :______________________
Referring)
Fax#: (____) _____________________________________ E-Mail Address: ____________________________________
Patient’s
Name:_______________________________________
Other Contact
Information
Telephone: Home (_____) ________________ Work (_____) __________________ Cell (_____) ________________
)
(if applicable
Insurance:_______________________
HMO
PPO
POS
Traditional
Medicare
None
Insurance
Information
Medicaid:
HMO
Other
Medicaid Insurance Plan:________________________________
Auto Accident?
Y
N
Date of Injury ___________ Work Comp?
Y
N Date of Injury_________________
Requesting
Physician Signature:
Physician
(Signature)
(Date)
Once you have faxed the form, please ask patient to call us to schedule an appointment at: (310)
794-1195. For clarification, please call (310) 794-1195.
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