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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 for Center for Neurological Learning and Development Disabilities

Relevant (clinical) information

Indication for referral

Further diagnostics and/or treatment (without indication for a specific diagnostic or treatment program)

Specific diagnostic program

Diagnostic (and treatment) children and young adults with a muscular disease

Diagnostic (and treatment) children and young adults with neurofibromatosis

Diagnostic (and treatment) children and young adults with traumatic brain injury

Second opinion

Other, namely...

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

If yes, with whom?

Note: Please send attachments, such as results of previous diagnostic investigations (e.g. pediatric neurologic examinations, (neuro)psychologic examinations) and correspondence, accompanied by the patient's information, per mail to:

Kempenhaeghe
attn. poliklinieksecretariaat Center for Neurological Learning and Development Disabilities
Postbus 61
5590 AB HEEZE