Beacon Health System
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Memorial Neurodiagnostic Services
Patient Name: ______________________________________________________ Patient DOB: _____________
(Please bring this sheet with you at time of service.)
Appointment Date: _________________ Arrival Time: _____________ Procedure Time: ___________
Diagnosis (ICD-10 Code Required): _______________________________________________________________
_____________________________________________________________________________________________
Ordering Physician (Signature): _________________________________________________________________
(Printed): __________________________________________________________________
(Date): _____________________________________ (Time):_______________________
Procedure Scheduled: Evoked Responses
Please check appropriate box:
← Ver. Ser. Baer Combination
← Somatosensory Evoked Response (90 min.)
← Somatosensory (SER) for Surgery (8 hr.)
← Brainstem Evoked Response/Tympanogram
← Visual Evoked Response
Prep: No prep.
About your procedure: Evaluates the auditory, optic and peripheral nervous systems. It is used to evaluate acoustic neuromas, brainstem tumors, hearing disorders, coma, brain death, demyelinating diseases, hearing in infants and small children and other patients unable to give voluntary, subjective responses to traditional hearing tests. It also evaluates the nerve pathway from the peripheral nerve through the spine to the somatosensory region of the brain and is used to evaluate the optic neuritis, optic tumors, and disease such as Multiple Sclerosis.
How to find us: Free valet parking is available for patients at the Main Entrance, or you may park in the Bartlett Street Parking Ramp (see map). When you arrive at Memorial, you must register for your procedure in Admitting, located in the Main Entrance area of the hospital to the rear of the Information Desk (see maps). If you have any questions, please ask the Main Entrance Information Desk. If you need assistance regarding scheduling, please call 647-7700.
647-7700
N1
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