Department of Clinical Neurophysiology

GP/primary care referral form for Nerve Conduction Studies, EMG (Electromyography) 0203 299 3151

kch-tr.neurophysiology@nhs.net

PATIENT DETAILS
NHS No
First name / Surname
DoB
Phone no
Email
Address
Postcode
Gender

GP name
GP Practice name
Practice address

Referrer details
Referrer organisation
Referral source
Inpatient/Outpatient?	Choose an item.
If Inpatient, which ward?
Current Consultant
Email address for report

Guidance on EMG and NCS

The following EMG/NCS orders are available. Choose the option with the highest number appropriate to the clinical situation, and add a comment if there is a more specific issue.

Carpal tunnel syndrome screening	☒	For ?CTS/median neuropathy
Upper limb simple NCS	☐	usually ulnar or other single nerves
Upper and lower limb NCS	☐	generalised neuropathies
NCS/EMG	☐	Any situation where needle EMG is likely to be needed to look for denervation or myopathy

Routine	☒	NHS	☒	Ambulant	☒
Urgent	☐	PP	☐	Chair	☐
Stretcher/Bed	☐

Reason for study:
Clinical details: (If insufficient space, attach clinic letter)

Referrer details:	Name:	Role:
Contact email:	Phone:
Date:	Click or tap to enter a date.

This form should be saved and attached to an email to kch-tr.neurophysiology@nhs.net