To make a booking please complete and submit the form below. Please note that individuals are welcome to make enquiries but a doctor’s referral letter is required before an appointment will be confirmed ( * indicates a required field).

If you require a Neurology consultation, please email .

Patient Details
Full Name *
Date of Birth *
Home Address *
Home Telephone Number
Mobile Telephone Number
Test Required *		Please select a test Standard Awake EEG                  Sleep Deprived EEG Simple NCS Complex NCS/EMG
Referring Doctor's Details
Full Name *
Date of Referral *
Address for Report *
Telephone Number *
Fax Number
Email Address
Referral Letter
NOTE: Only Microsoft Word documents with a file size less than 2MB can be attached using this form.
Please enter the two security words as you see them above before submitting the form.