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Mary L. Lussier MD 588 Pawtucket Ave. Pawtucket RI 02860 Phone 401-722-2400 Fax 401-728-3920 Attn Referral Coordinator EMG/NCS REFERRAL FORM Date // Patient s Name DOB// REASON FOR REFERRAL UPPER EXTREMITY LEFT RIGHT BILATERAL Carpal Tunnel Median n. at wrist Ulnar Neurop at Elbow cubital Brachial Plexus Cervical Radiculopathy Guyon Ulnar at wrist Other Diagnosis/Symptoms LOWER EXTREMITY Lumbosac Radic Peroneal N. Peripheral Polyneuropathy Referring Physician Phone Office...
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