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Services
  Sleep Medicine
  Electromyography and      Nerve Conduction studies
  EEG
  Stroke Care and Neuro      Rehabilitation
  Pediatric Neurology      evaluation
  Botulinum Toxin treatment
  Attention Deficit Disorder      treatment
  Physical Therapy
     Movement Disorders
 
DBS Management
     Epilepsy
 
VNS Management
     Neuromuscular Disorders
 
Infusion Therapy
Physician Information
 
 
Physician Referral
       
  Date Referring Physician
  Patient Name  
  Date of Birth SSN
  Address  
 
City
State
Zip
  Home Phone Work Phone
  Diagnosis  
  Insurance Phone
  Insurance Policy Group
  Authorization  
  Policy holders name if different from Patient  
  Please list relationship to insured  
Please fill out the above information. An appointments representative will call and confirm information and appointment time.
 
Please check which Dr you would like the appointment with.
         
    Adult Providers    
         
  Dr. James Pugh Dr. Frederick Pfeiffer
  Dr. Erik Borresen Dr. Michael Amiri
  Wesley Myers, NP Dr. Kenneth Ashkin
  Dr. Kurt Washburn    
         
    Pediatric Providers    
         
  Dr. Carolyn Hart Dr. Robert Nahouraii
  Debra Weaver, CPNP Angela Noone, CPNP