The Clinical Neurology Specialists referral form captures patient and insurance details, the referring clinician's information, the clinical question and the requested service. It is available as a PDF, and a Spanish-language version is available for patients who need it.
The Clinical Neurology Specialists referral form captures patient and insurance details, the referring clinician's information, the clinical question and the requested service. It is available as a PDF, and a Spanish-language version is available for patients who need it.
Patient identifiers and contact details, insurance information including plan name and member number, the referring clinician and practice with a direct contact for results, the reason for referral, and the specific service requested. The reason for referral is the field that most affects how the case is triaged, and the one most often left as a single word.
A current medication list with doses, recent relevant laboratory results, imaging reports rather than the images themselves, prior neurology notes, and any previous electrodiagnostic or EEG studies. Prior studies are worth sending even when several years old, because comparison over time changes interpretation.
The commonest causes of a referral being returned are a missing insurance number, no direct contact for the referring clinician, and a request naming a test without stating the question it should answer. Patients must be 18 or older, which is worth checking before the form is completed rather than after. If you are referring a patient who prefers Spanish, note that on the form so the appointment is arranged with language support from the outset rather than resolved on the day. Note any mobility or access needs in the same place, since both are far easier to plan for in advance than to accommodate on arrival.
Clinical Neurology Specialists has been physician-owned since 1998, when Leo Germin, M.D., FAANEM founded it. Five board-certified neurologists and four advanced practice providers see patients at the Las Vegas and Henderson offices, each with its own AANEM-accredited electrodiagnostic laboratory.
Clinical Neurology Specialists is an adult outpatient neurology practice for patients 18 and older. The practice performs no surgery and operates no imaging suite, infusion suite or interventional pain programme, and provides no emergency or inpatient care.
The practice referral form is available as a PDF, and a Spanish version is available for patients who prefer it.
Physician-reviewed. Reviewed by the physicians of Clinical Neurology Specialists — board-certified neurologists, AANEM-accredited electrodiagnostic laboratories, physician-owned since 1998. Reviewed 1 August 2026. This article is general education for adults 18 and older and is not a substitute for a consultation.
Sources and further reading: American Academy of Neurology; MedlinePlus, National Library of Medicine; American Association of Neuromuscular & Electrodiagnostic Medicine.
Adults 18 and older, at the Las Vegas and Henderson offices. Call 702-804-1212 or request an appointment online.