Neurology

Phone: (585) 922-4371
Fax: (585) 922-7485

Department of Neurology
Rochester General Hospital

Requisitions For Electromyography (EMG) /
Nerve Conduction Study (NCS)

 

Referring Physician Information

Referring Physician Name:

Phone:

Email:
 

Patient Information

Patient Name:

Phone:

DOB (00/00/0000):
 

Patient's Clinical Problem / Symptoms

Please list the patient's clinical problem and / or symptoms below.

 

Provisional Diagnosis

Please select all that apply from the list below.

:

:

:

: ROOTS: AND

: ROOTS: AND

:

:







:

 

Special Studies Requested

Please select special studies requested below.



 

Special Information

Please answer the following questions about your patient.

*** IMPORTANT NOTE: Patient's Cardiologist Approval - Click here to print the cardiologist letter of approval

Does the patient have a pacemaker?

Does the patient have an AICD?

Is the patient currently on anticoagulants?

Date of Last INR? VALUE:

Interpreter Needed? --- LANGUAGE:

   
 
 

1425 Portland Ave Rochester, NY 14621
Phone: (585) 922-4410
Fax: (585) 338-7485