Neurodiagnostic Services Forms

To schedule an appointment, please call Centralized Scheduling at 574-647-7700. Fax orders to 574-647-2200.

Evoked Responses (PDF)

• Ver. Ser. Baer Combination
• Visual Evoked Response
• Somatosensory Evoked Response
• Somatosensory (SER) For Surgery
• Brainstem Evoked Response/Tympanogram

EEG - w/prep (PDF)

• Electroencephalogram (90 min.)
• 48 hour Ambulatory- Initial
• 48 hour Ambulatory 24hr. F/U visit
• 48 hour Ambulatory 48hr. F/U visit
• EEG video
• 24 hour Ambulatory- Initial
• 24 hour Ambulatory F/U visit

EMG (PDF)

• EMG 30 min All Diagnoses
• EMG 45 min. (Except Bilat Lower Extremity)
• EMG Bilateral Lower ExtremityNerve Conduction Velocity Study