Please ensure that you have a signed valid referral.

If a valid (dated @amp; signed) referral is not provided before the test, the testing may be cancelled at short notice or you may have to pay for the full test cost upfront and will not be eligible for a medicare rebate or will not be bulk-billed. This is non-negotiable. If you do not have a referral and have chosen to book for the test online, please ensure that a referral has been sent and actioned atleast 1 business day before your test is due.

All Work Cover cases need a valid pre-approval before any testing is undertaken. Likewise, a valid pre approval for DVA Whitecard Holders is essential. If this is not the case, you can still undergo the test but will be responsible for paying the costs upfront (at AMA gazetted rates) and will have to claim this back from WC , DVA or Third-Party insurer after testing is completed.

1. It is important to have clean ears without wax and no make-up before undergoing hearing and balance testing.

2. Please ensure both ears are checked for wax and cleaned professionally before you undergo vestibular function testing.

3. Please do not wear any make-up on your face. Avoid using any hair products such as hair spray or gel.

4. If you have undergone an audiogram recently, please bring a copy of your recent audiogram report.

5. If you are suffering from significant dizziness/vertigo, please bring a support person and do not drive especially after the test.

6. Please DO NOT take any vestibular sedatives such as Stemetil, Serc or cinnarizine/flunarizine for atleast 48 hours before testing.

Please wear loose-fitting clothes.

It may be essential to partially undress for some tests (access to the upper shoulder, thigh, groin area or back may be necessary).

A disposable gown can be provided on request. Please bring a support person if the presence of a chaperone is necessary.

EEG Appointment Instructions

1. If a Sleep-deprived EEG has been requested, please ensure that you have no more than 4 hours of sleep the night before the test.

2. No caffeine for at least 12 hours prior to the test.

3. Your hair needs to be clean and dry (The tech may use wax to attach electrodes to your head so your hair may be messy afterwards).

4. It is important to continue to take your prescribed anti-seizure medications (unless you have been advised explicitly in writing to discontinue them before EEG testing).

I. PURPOSE OF INFORMED CONSENT

The purpose of this Informed Consent is to describe electrodiagnostic testing that was deemed appropriate by your physician for the purpose of diagnosis of your condition, as well as to inform you of the possible benefits and risks of undergoing such testing, to inform you of alternatives to such testing and risks of not undergoing such testing. Your participation in the prescribed electrodiagnostic testing is strictly voluntary.

II. DESCRIPTION OF TESTING

Electrodiagnostic testing that your physician has prescribed consists of obtaining a directed history of health and medical problems, a neurological examination, a Nerve Conduction Study (NCS), and Electromyography (EMG). All of these components are referred to in this Informed Consent as “Electrodiagnostic Testing”.

Nerve Conduction Studies

Nerve conduct electrical signals generated in certain areas of the brain. These signals are carried through nerves to muscles. Upon receiving these signals, or stimuli, muscles contract and perform movements. If muscles do not respond to such stimuli correctly, it is possible that corresponding nerves are not functioning properly. A Nerve Conduction Study is performed to establish whether nerves carry (or conduct) stimuli normally. In order to perform a Nerve Conduction Study, surface electrodes are taped over several zones on the skin and muscles. The nerves which supply those zones or muscles are then stimulated with a surface probe and the resulting electrical responses are recorded by the surface electrodes, which are in turn attached to an EMG machine. The electrical responses provide detailed information about nerve function. These stimuli feel like a small shock (as a pinch or tingling) and are almost always well tolerated. One or more nerves may be tested during this procedure.

Electromyography

If muscles do not respond correctly to stimuli produced in the brain and conducted to these muscles by corresponding nerves, it is possible that the muscle does not process these stimuli normally, even though the nerves are intact. To establish whether this is true, electromyography is performed. During this test, a very small disposable needle electrode (smaller than the needle employed during a blood draw) is placed in one or more muscles. The electrical activity of the muscle is fed back through the electrode to the EMG machine when the muscle is at rest and then when it is voluntarily activated by the patient. The information obtained from EMG provides insight into muscle function.

Hearing and Balance Tests

Hearing and balance tests involve irrigation of your ear canals by warm or cold air (safer alternative to warm or cold water). This is safer even when there may be a perforated ear drum. The risk of ear drum perforation with electrocochleography (if specifically requested) for Meniere's disease is absolutely minimal with the use of transtympanic electrodes (currently not used in our practice where we use gold foil electrodes (tip-trodes) that are placed superficially in the external ear canal. Examination for benign positional vertigo with the video head impulse testing involves minor sudden headshakes performed by the technician. The movements are really small and unlikely to cause any head or neck injury.

Test Results

At the end of the study, the results of the neurologic examination, the NCS and EMG are combined to diagnose problems with nerves and muscles and connections between them (neuron-muscular junctions), as well as areas in the brain that control these nerves and muscles.

III. POSSIBLE BENEFITS OF ELECTRODIAGNOSTIC TESTING

Electrodiagnostic medicine is the study of diseases of nerves and muscles. Your doctor has recommended an EMG test to see if your muscles and nerves are working right. The results of the tests will help localize the problem and establish its severity. Benefits of electrodiagnostic testing may be decreased by factors that interfere with the testing and affect its accuracy. These factors include medications such as muscle relaxants and anticholinergics, presence of excess fatty tissue between the muscle and skin, application to the skin of medicinal and/or cosmetic lotions or creams, patient’s ability to cooperate with the physician during testing, or patient’s failure to follow physician’s instructions, as well as patient’s age (nerve conduction can vary with age and normally decreases as a person grows older).

IV. POSSIBLE RISKS OF ELECTRODIAGNOSTIC TESTING

Electrodiagnostic testing involves insertion of disposable needle electrodes into skin and muscles and electrical stimulation of muscles (EMG). As such, they may cause discomfort and pain during the test. Since every patient tolerates discomfort and pain differently, it is impossible to predict how discomforting and/or painful this test will be for you. Most patients describe the discomfort as mild. Minimal bleeding may occur during or after the test at the site of insertion of needle electrodes. Therefore, it is very important for you to disclose to your physician whether or not you have a bleeding problem, or whether or not you have been taking blood-thinning medication, such as Coumadin or Heparin. Electrodiagnostic Testing may interfere with the electrical devices implanted in the body. Therefore, it is very important for you to disclose to your physician if you have such a device implanted in your body (for example, a pacemaker in the heart, defibrillator, cochlear implant, or spinal cord simulator). Even though sterile, disposable electrodes are used for Electrodiagnostic Testing, the site of insertion of needle electrodes may become infected, although the risk is minimal. This risk elevates, however, if normal hygiene is not maintained after the completion of the test. After the test, the muscle (or several muscles) may feel tender and bruised for a few days. Overall, Electrodiagnostic Testing is safe and electric stimulation is too weak and short to cause an injury or permanent damage. By signing this Informed Consent below, you affirm that you have read and understood possible risks that may result from Electrodiagnostic Testing and have voluntarily assumed these risks for the benefit of undergoing Electrodiagnostic Testing. By attending your appointment for the electrodiagnostic testing, by proxy, you agree not to hold Pacific Neurology, its directors, shareholders, business associates, physicians, nurses, and other employees liable for any occurrence of such risks.

V. ALTERNATIVES TO ELECTRODIAGNOSTIC TESTING

Electrodiagnostic tests such as Nerve Conduction Studies and/or Electromyography collect and analyze very specific information about the proper function of my nervous system and my muscles. No other test can record and analyze electrical activity of nerves and muscles these nerves innervate and, therefore, there is no substitute, or alternative test, that can provide my physician with the information needed.

VI. RISKS OF NOT UNDERGOING ELECTRODIAGNOSTIC TESTING

Risks of not undergoing Electrodiagnostic Testing include delay in proper diagnosis, delay in localization of possible problems affecting nerves and muscles, delay in assessment of severity of such problems, and delay in treatment and/or rehabilitation that might have been recommended had Electrodiagnostic Testing been performed.