Electrodiagnosis & Rehabilitation Associates of Tacoma, P.S.

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 - referrals@electrodiagnosis.net or referrals@electrodx.com
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’.