Referring Provider Name*
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Fax Number
Patient Information
Patient Name*
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Referral Information
Reason for Referral*
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Musculoskeletal Evaluation
EMG / NCS
Interventional Procedure
Other
Musculoskeletal Evaluation
Body Region
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Cervical Spine
Thoracic Spine
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Shoulder
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Other
Laterality
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Right
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EMG / NCS
Symptom/Indication
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Radiculopathy/Suspected Nerve Root Compression
Peripheral Neuropathy
Entrapment Neuropathy (e.g. carpal tunnel, cubital tunnel)
Plexopathy
Sensory Symptoms (numbness, tingling)
Other
Other
Interventional Procedure
Procedure Type
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Ultrasound-guided Injection
Fluoroscopic-guided Injection (consult required prior to scheduling the procedure)
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For injections (US or fluoro):
Target Area/Structure
Laterality
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Right
Left
Bilateral
Axial
For Botox:
Indication
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Spasticity
Cervical Dystonia
Chronic Migraine
Other
Other
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