Stroke Care Referral Information




Level 5, East Pavilion
Medical Center Campus
111 Colchester Avenue, Burlington, VT 05401

Office Hours:   
Monday-Friday, 8:00 am-5:00 pm

Referral Information
This is information the Neurologist needs to provide the best care for your patient.

Questions and Issues For You to Consider When Referring Your Patients
1.     Please ask patient to bring all their medications and personal medical records to the appointment.
2.     Patients referred for Spasmodic Dysphonia should also have an ENT consult scheduled prior to the visit with the Neurologist.
3.     If there is a current exacerbation due to Multiple Sclerosis, please refer the patient.

Medical/Surgical Information
Most Important
1.     Name of Referring MD/Provider / Phone / Fax
2.     Reason for Referral and Expectations
3.     Most Recent Office Note Pertaining to the Visit
4.     Medication / Allergy List
5.     Previous Course of Treatment
6.     EEG
7.     Most Recent Lab Tests
8.     Imaging Films and Reports of Head, Neck or Spine Including MRI, CT, Angio, SPECT, PET and /or Myelogram

Please send the following information if pertinent to the referral.
1.     Outside Consult Reports
2.     Hospital Discharge Summary and Medications
3.     Pathology Reports
4.     Laboratory/Blood Urine Test Results
5.     Results of Electrophysiology Testing

Please send the following information if possible. It is desirable, not essential.
1.     Problem List
2.     Medical / Surgical History
3.     Nuclear Medicine Reports
4.     Operative Reports if Pertinent

Diagnosis-Specific Information
1.     Cervical Dystonia and other Focal Dystonias:  Please Send Serum Ceruloplasm
2.     Multiple Sclerosis:  Please Send Lumbar Puncture Results if Already Performed, Evoked Potential Studies, Neuroimaging

Patient Demographic Information
Name, Date of Birth, Address, Phone Number, Insurance Plan, Worker’s Compensation, if applicable