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Patient information

Name

Address

Postal code

City

Date of birth

Phone number

Referrer

Name*

Address 1

Address 2

Postal code

City

Phone number

E-mail

Question

Complaint

Indication for referral

Specific diagnostic program:

Further diagnosis and/or treatment (without indication for specific diagnostic- or treatment program ahead of time)

Differential diagnostics of seizures

Second opinion

Medication advice because of

Insufficient freedom of seizures

Side effects

Interaction with other medication

Study of possible drug-free treatment

Taking over treatment

Examination and/or guidance in connection with psychosocial problems

Other, namely...

Has the case been discussed with a practitioner at Kempenhaeghe? No Yes

If yes, with whom?

Note: Please send attachments, such as results of previous diagnostics (MRI, EEG) and other correspondence, together with patient information, to:

Kempenhaeghe
attn. polikliniek secretariaat Academic Center for Epileptology
Postbus 61
5590 AB HEEZE