Electrodiagnosis & Rehabilitation Associates of Tacoma, P.S. Diplomates American Board of Neuromuscular & Electrodiagnostic Medicine * Diplomates American Board of Physical Medicine & Rehabilitation § SURINDERJIT SINGH, M.D., M.S., F.A.A.N.E.M.*, F.A.A.P.M.R.§ Emeritus MOHAMMAD A. SAEED, M.D., M.S., F.A.A.N.E.M.*, F.A.A.P.M.R.§ . . . . . . . . . Tacoma & Lakewood EDGAR S. STEINITZ, M. D., F.A.A.N.E.M.*, F.A.A.P.M.R.§, F.A.B.P.M. . . . . . . Tacoma & Puyallup TABASSUM SAEED, M.D., M.S., F.A.A.N.E.M.*, F.A.A.P.M.R.§ . . . . . . . . . . . . Federal Way TACOMA MAIN OFFICE 2201 SOUTH 19TH STREET, #104 TACOMA, WA 98405 EMG/NCV (253) 272-9994 (800) 319-2677 PM&R FAX (253) 572-0468 HUI WANG, M.D., M.S., F.A.A.P.M.R.§ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tacoma www.electrodiagnosis.net www.electrodx.com - - PLEASE VISIT OUR WEB SITE - WWW.ELECTRODIAGNOSIS.NET OR WWW.ELECTRODX.COM PATIENT REFERRAL FORM Please instruct the patient to schedule by calling our office Fax referrals accepted; as well as electronic submissions Office Number (253) 272-9994 or (800) 319-2677 Fax Number - (253) 572-0468 Email - [email protected] or [email protected] Patient Name _______________________ Phone # - Home ___________ Cell ____________ Work __________ Social Security # _________________ DOB ____________ Special Needs/ (Interpreter) __________________ Address ___________________________________ City, State, Zip _____________________________________ Insurance __________________________ Claim # (L&I; other ) ____________________________________ Diagnosis _________________________________ Reason(s) for referral ________________________________ Referring Physician ________________________ Phone # __________________ Fax _____________________ If Physician Preference – Schedule with Dr(s). ____________________ Request only Dr. _______________ If known, preferred office for your patient ______________________________________________________ If already Scheduled: Physician ________________ Date & Time _________ (check office location below) Electrodiagnostic (EMG/NCS) Study & Consultation – Request Expanded Recommendations Based Upon EMG/NCV Findings LUE RUE BUE Alert: Coumadin anticoagulation LLE RLE BLE Cardiac Defibrillator Brain Stimulator Somatosensory Evoked Potentials (SEP)/Dermatomal Somatosensory Evoked Potentials (DSEP) PM&R Consultation – Spinal/Musculoskeletal Neuro-Rehab Workers Comp- Transfer of Care Pain Management Other ____________________________________________________ TACOMA MAIN OFFICE 2201 S. 19TH ST., #104 TACOMA, WA 98405 (253) 272-9994 (800) 319-2677 FEDERAL WAY OFFICE 34617 - 11TH PL. S., #101 [700 S. 320th, ‘D’- Office 2] FEDERAL WAY, WA 98003 GIG HARBOR OFFICE ST. ANTHONY BUILDING 4700 PT. FOSDICK DR. N.W., #213 GIG HARBOR, WA 98335 LAKEWOOD OFFICE PUGET SOUND ORTHO 7308 BRIDGEPORT WAY W., #201 LAKEWOOD, WA 98499 PUYALLUP OFFICE MERIDIAN REHABILITATION 1707 3RD ST. S.E., ‘A’ PUYALLUP, WA 98372 - SEE BACK PAGE FOR DETAILS ABOUT ELECTRODIAGNOSTIC STUDY & OUR PM&R SPECIALTY - - - SEE BACK PAGE FOR DETAILED DIRECTIONS & MAPS TO OUR OFFICES - Alert: If this is a FAX transmission, it may concern confidential information protected by the Patient/Physician privilege intended for use solely by the entity named above. If you are not the intended recipient, you are hereby notified that law strictly prohibits any disclosure, copying, distribution, or the taking of any action in reliance on the contents of this information. If you received this transmission in error, please notify us by phone to arrange for return of the document(s). - - ELECTRODIAGNOSTIC EMG/NCS MEDICINE PATIENT INFORMATION - Your doctor or health care provider has requested an Electrodiagnostic EMG/NCS study which is performed by physicians with specialized training. We hold the highest National Certification by AANEM – Full Accreditation Exemplary Status. The procedure is an extension of the clinical presentation and physician’s examination, and helps to determine if your problem affects the nerves and muscles in your body. Please arrive 10 minutes early for registration. No special preparation is required, except to keep the skin free of any body lotion on the day of the examination. You do not need to limit food or medications except if you are being evaluated for Myasthenia Gravis. After the tests are completed, you may carry on your normal daily routine. The electrodiagnostic physician interprets the results of your study, and completes a detailed report which is sent to the referring physician/provider by mail, email &/or fax. He/she will then be in the best position to coordinate further treatment. Electrodiagnostic Study is a procedure which commonly includes two components: Electromyogram (EMG) Nerve Conduction Study (NCS) During an EMG study, the physician analyzes the electrical activity in muscles by inserting a fine pin electrode. Electrode insertion may cause mild temporary discomfort. The physician can determine whether the muscle, and the nerve supplying that muscle, is working properly by analyzing the firing pattern on a video monitor and listening over a loudspeaker. Evaluation of both the resting muscle membrane as well as the recruitment pattern from the muscle fibers yields valuable information. Only brand new, laboratory sealed and sterilized disposable needles are used for every patient which are discarded after use to prevent transmission of infection including AIDS or hepatitis. During NCS, the physician tapes small electrodes on the skin and applies a brief electric stimulus to different portions of motor and sensory nerves. Nerve stimulation causes a tingling sensation. The physician evaluates the electrical responses of the nerve or muscle being tested and can determine if the nerve impulse is (a) conducted normally, (b) at a slow speed, or (c) not transmitted at all. Resources on EMG/NCS & SEP study, including an educational video: http://www.electrodiagnosis.net/EMG_NCS/Overview.html EMG/NCV Study Video – ‘Click to Play’ Normal & Abnormal EMG Normal & Abnormal NCS - - SEP STUDY - Somatosensory Evoked Potential (SEP) Dermatomal Somatosensory Evoked potential (DSEP) On occasion, other specialized studies may be requested to include: Somatosensory Evoked Potential & Dermatomal Somatosensory Evoked Potential study is a specialized type of sensory NCV testing of peripheral nerves or any cutaneous site. Surface electrodes record the electrical responses utilizing computer averaging techniques measuring nerve conduction in an extremity, and through the spinal cord and brain. - - COMBINED SPECIALISTS OF ELECTRODIAGNOSTIC MEDICINE AND PM&R - We have advanced training in the evaluation and treatment of muscle and nerve function and are Board certified by the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). We can often determine the etiology of weakness, muscle atrophy, fatigability, pain, numbness and tingling. We are also Board certified by the American Association of Physical Medicine & Rehabilitation (AAPM&R) with expertise in maximizing functional potential for conditions including but not limited to: Disc problems & spinal stenosis Stroke Ligament, tendon & joint problems Nerve root lesions Head trauma Muscle diseases Peripheral nerve entrapments Spinal cord injury Fibromyalgia Soft tissue & whiplash injuries Amputation Pain management - - DETAILED DIRECTIONS & MAPS TO OUR OFFICES - TACOMA- MAIN OFFICE (253) 272-9994 (800) 319-2677 TH 2201 S. 19 ST., #104 TACOMA, WA 98405 2201 S. 19th S 19th St. From I-5 (towards Bremerton-Gig Harbor). Exit #132B onto Hwy. 16. Immediately Exit 1A for Sprague Ave. Turn Left at 1st light, S. 19th St. Travel a few blocks to Trafton St. Light (7-11 Store across the Street). Right into parking lot of 2201 Medical Center, 1st floor, Suite #104. From Gig Harbor/Tacoma Narrows Bridge (towards I-5 & Tacoma). Hwy. 16. Exit 1A Sprague Ave. Turn Left at 1st light, S. 19th St. Travel a few blocks to Trafton St. Light (7-11 Store across the Street). Right into parking lot of 2201 Medical Center, 1st floor, Suite #104. Sprague Ave. Hwy. 16 Suite #104 I-5 FEDERAL WAY OFFICE TH 34617 - 11 PL. S., #101 TH [700 S. 320 , ‘D’ – Office 2] FEDERAL WAY, WA 98003 GIG HARBOR OFFICE LAKEWOOD OFFICE PUYALLUP OFFICE ST. ANTHONY BUILDING PUGET SOUND ORTHO MERIDIAN REHABILITATION 4700 PT. FOSDICK DR. N.W., #213 7308 BRIDGEPORT WAY W., #201 1707 3RD ST. S.E., ‘A’ GIG HARBOR, WA 98335 LAKEWOOD, WA 98499 PUYALLUP, WA 98372 I-5 Southbound Olympic Fox Dr. N.W. 74th St. W. 34617 11th Pl. Hwy. 99 Pt. Fosdick Dr. N.W. I-5 Puget Sound Ortho Hwy. 16 th S 348 St. ‘700 320th’ – From I-5 Exit #143 – 320th St. Westbound across Hwy. 99 & 8th Ave. S. to ‘700’320 th . From Tacoma Narrows Bridge Hwy. 16 Exit #10/Gig Harbor. Left/West on Olympic Fox Dr. NW; From Bremerton, Exit Right/West. Left on Pt. Fosdick Dr. NW ~1/10 mile past Safeway: St. Anthony’s- Right into 4700 Pt. Fosdick Dr. NW, Enter St. Anthony’s Building, Elevator to 2nd floor, Suite #213. S. Meridian 15th Ave. S.E. Brain & Spine Center Bridgeport Way S.W. St. Anthony’s ‘34617 11th PL.’ From I-5 South or Northbound Exit #142B/#142. West on S. 348th St. across Pacific Hwy. Right on 11th Ave (just past Animal Hosp. & Twin Lake Chiropractic on Right). Go up hill to 34617 Medical Building. Go to Suite #101. Multicare Hwy. 512 3rd St. S.E. Meridian Rehab Multicare I-5 Northbound From I-5 Southbound Exit #129/ 74th St. W. ~2.3 miles (becomes Custer Rd. W.). Right on 75th St. W., Right on Bridgeport Way W., ½ block, Left into Puget Sound Orthopedics, From Northbound I-5 Exit #125/ Bridgeport Way S.W. ~2.6 miles. North (across Gravelly Lake Dr., Custer Rd. & 75th W.) ½ block, Left into Puget Sound Orthopedics, Suite #201. Hwy. #512 Exit Meridian S. South up hill to 1st light past Jason’s. Left on 15th Ave. S.E. (corner Hampton Inn; follow blue signs to hospital). Right onto 3rd Street S.E (1stmajor intersection, ¼ turn around traffic circle past Brain & Spine Center to Rieder Medical Building- II. Left into Meridian Rehab Center, Suite ‘A’.
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