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info@whycni.com
MENU
MENU
Physicians
Neurology
Neurosurgery
Back & Neck Surgery Options
Post surgical care
Other Surgical procedures
Neurological Disorders
Carpal Tunnel & Nerve Pain
Neurodegenerative Diseases
Dementia & Alzheimer’s
Headaches & Migraines
Concussions
Insomnia
Contact Us
About
Patient info
Locations
PHYSICIAN REFERRALS
Referral
Patient Referral/Consult Request Form
Patient Name
*
Patient Phone
*
Referring Physician
*
Check "YES" if referring from an Urgent Care
Yes
No
Patient Address
*
Patient DOB
*
Requested Neurosurgeon
W Brent Faircloth, MD
Edward R Flotte, MD
Troy H Middleton III, MD
Donald R Tyler II, MD
First Available Neurosurgeon
Requested Neurologist
Thomas E Foster, MD
Richard A Friedman, MD
Timothy P Hecker, MD
Curtis M. Keller, MD
Andrew T Manley, MD
Charles S Markle, MD
Ozgur Ortas, MD
First available Neurologist
Reason for Consult
Headache/Migraine
Memory/Dementia
Numbness/Neuropathy
Weakness/Muscle Disease
Epilepsy/Seizures
Stroke/Vascular events
Parkinson's/Movement Disorder
Sleep Disorders
Multiple Sclerosis
Result of Motor Vehicle Accident
Results of a Work Comp Injury
Other
If Other, please describe.
Surgical Consult
Cervical
Thoracic
Lumbar
Cranial
Special Request:
Consult
Second Opinion
EEG
EMG/Nerve Conduction Study
Referring Office Phone #
*
Referring Office Fax Number
If you would like to be notified of the patient's appointment date & time please add your email below:
Date
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