This section is only for health care provider or their representatives. Please enter only if you are authorize to initiate a neurology or pain consultation.

Please fill this simple form out for in-patient and out-patient consultation. If this is emergency, we suggest you also page the physician or call our office as well.

* indicates required field

Patient Details

First Name:*
Last Name:*
Date of Birth:*
S. S. No / Hospital No:*

Consult Details

Desired place of consultation: *
If above is in-patient then room no:
How soon patient need to be seen?
Reason for consultation:*
Physician requesting the consult:*  
If above is other then please specify:  
Phone or Pager No: Atleast one of the following fields must be filled in order to accept the consult request
Fax No:
Name of the person filling the request:*  
Contact No:*