First seizure referral form
Please send if you have a patient with a first seizure and a suspected diagnosis of epilepsy
PATIENT DETAILS
Name
Date of Birth
Hospital Number
Address
(use label)
*Contact Number *
essential as appointments are at short notice
REFERRAL DETAILS
Date
Referer
Area/ Contact number
DETAILS
Description of what occured, treatment given, response, medical history, medications and
any other relevant details
Please send fax to:
FAO Rebecca Case/Sarah Kerley
Epilepsy nurse specialists
Wessex Neurological Centre
Southampton General Hospital
Telephone: 023 8120 8623
Fax number: 023 8120 8793
Or email form to: epilepsyspport@uhs.nhs.uk