Urgent Referral Form
You have reached the Houston Specialty Clinic - myspecialist.clinic

This is an online form to secure rapid specialty consultation from Emergency or Inpatient Care.

Dr. Rotenberg offers access to pediatric epileptology, pediatric neurophysiology.

Dr. Susarla offers pediatric pulmonary care.

We offer child-centered urgent evaluations for seizures / epilepsy, asthma, brain injury/concussion.

Please note that this data may contain personal health information. It will be encrypted and remain within the Google server.

Has llegado a la Clínica de Especialidades Houston - myspecialist.clinic

Se trata de un formulario en línea para asegurar la rápida consulta de neurología pediátrica de emergencia o Atención para pacientes hospitalizados .

Nuestra práctica ofrece acceso a epileptolgy pediátrica , la neurofisiología pediátrica , pulmonolgy pediátrica.

Ofrecemos evaluaciones urgentes centradas en el niño para las convulsiones / epilepsia, asma, lesión cerebral / conmoción cerebral.

Tenga en cuenta que estos datos pueden contener información personal de salud . Se encripta y permanecer dentro del servidor de Google .

Houston Specialty Clinic - Dr. Rotenberg, Susarla & PA Schmidt
Pediatric Neurology / Neurophysiology, Pulmonary & Sleep Medicine for the Houston Area
What is the patient's NAME? *
Your answer
What is the patient's AGE? *
Your answer
What is the patient's GENDER? *
Required
What is the patient's / patient's family best phone number? *
So that we can contact them
Your answer
What is the patient's / patient's family's best email? *
So that we can contact them
Your answer
What is the reason for urgent referral? Neurology or Pulmonary? *
Required
Has the patient had any tests?
Please note that we will coordinate EEG from our office.
Testing Site
So that we can gather this data, where was this testing completed?
Please add any relevant history or questions?
Your answer
What is the name of the referring physician / APN / other professional? *
Your answer
What is the PHONE Number for the referring professional? *
For privacy reasons, we ask for a personal identifier from our referring colleagues.
Your answer
What is the LICENSE Number for the referring professional? *
For privacy reasons, we ask for a personal identifier from our referring colleagues.
Your answer
What is the primary practice name? *
Your answer
Request for Urgent Consultation *
By clicking agreement this question, you are requesting an urgent consultation with Houston Specialty Clinic, or its designees .
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