Home
Clinic
Multiple Sclerosis
Parkinson’s Disease
Alzheimer’s Disease
Neuromuscular
Glioblastoma Multiforme
Stroke Care and Recovery
Services
Team
MS Protocols
Clinical Trials
Multiple Sclerosis (MS)
Myasthenia Gravis (MG)
Parkinson Disease (PD)
Multifocal Motor Neuropathy (MMN)
Amyotrophic lateral sclerosis (ALS)
Alzheimer’s Disease (AD)
Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)
Glioblastoma Multiforme (GBM)
Neuro Rehabilitation
rTMS
Infusion Clinic
Contact
English
Français
(
French
)
Home
Clinic
Multiple Sclerosis
Parkinson’s Disease
Alzheimer’s Disease
Neuromuscular
Glioblastoma Multiforme
Stroke Care and Recovery
Services
Team
MS Protocols
Clinical Trials
Multiple Sclerosis (MS)
Myasthenia Gravis (MG)
Parkinson Disease (PD)
Multifocal Motor Neuropathy (MMN)
Amyotrophic lateral sclerosis (ALS)
Alzheimer’s Disease (AD)
Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)
Glioblastoma Multiforme (GBM)
Neuro Rehabilitation
rTMS
Infusion Clinic
Contact
English
Français
(
French
)
Contact Us
Patient or physician, we look forward to hearing from you.
Visit the Clinic
Clinique Neuro-Outaouais,
209, Gamelin Street, suite 200
Gatineau, QC, J8Y 1W2
Phone or e-Mail
T: (819) 777-2500
F: (819) 777-2502
info@neuro-outaouais.ca
EMG Requisition Form
Referral form for Electroneurophysiology
(Fees covered by RAMQ and OHIP)
Patient information :
Place sticker with complete patient information :
Physician information :
Date:
Physician name :
Fax:
Address :
Electrophysiology Tests:
EMG with consultation
Carpal Tunnel Syndrome Evaluation with consultation
Visual evoqued potentials
Motor evoqued potentials
Clinical information :
Submit
