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Neurology
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Neurological Disorders
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info@whycni.com

MENUMENU

Physicians
Neurology
- Aimovig™
Neurosurgery
Neurological Disorders
Referrals
About
- Patient info
- Locations
BOOK AN APPOINTMENT

Referral

Patient Referral/Consult Request Form

Patient Name *

Phone *

Patient DOB *

Referring Physician *

Office Location Requested *

Requested Physician

First available Neurologist

Thomas E Foster, MD

Richard A Friedman, MD

Timothy P Hecker, MD

Andrew T Manley, MD

Charles S Markle, MD

Ozgur Ortas, MD

First Available Neurosurgeon

W Brent Faircloth, MD

Edward R Flotte, MD

Troy H Middleton III, MD

Donald R Tyler II, MD

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

If you would like to be notified of the patient's appointment date & time please add your email below:

Fax Number (If needed for follow up)

Date

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