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PHYSICIAN ORDER FORM
Patient Name
*
First Name
Last Name
Date of Birth: (ex: Month, Day, Year: January, 01, 1990)
MM
DD
YYYY
Imaging/Lab Order(s):
Outside Provider Referral(s):
MEDICINE & SURGERY
PAIN MANAGEMENT (INTERVENTIONAL)
KARAN JOHAR, MD
First Available (Pain Management Physician)
Follow-up - 1-Week
Follow-up - 2-Weeks
Follow-up - 3-Weeks
Follow-up - 4-Weeks
Follow-up - 10-Weeks
MEDICATION MANAGEMENT
PHYSICIAN ASSISTANT - TEDDY O. UZAMERE, PA-C
PHYSICIAN - JUAN-CARLOS MARTINEZ-BARRERA, MD
First Available (Medication Management)
Follow-up - 1-Week
Follow-up - 2-Weeks
Follow-up - 3-Weeks
Follow-up - 4-Weeks
Follow-up - 10-Weeks
INTERNAL MEDICINE
PHYSICIAN ASSISTANT - TEDDY O. UZAMERE, PA-C
First Available (Internal Medicine)
Follow-up - 1-Week
Follow-up - 2-Weeks
Follow-up - 3-Weeks
Follow-up - 4-Weeks
Follow-up - 10-Weeks
Sports Medicine
PHYSICIAN - JUAN-CARLOS MARTINEZ-BARRERA, MD
First Available (Sports Medicine Physician)
Follow-Up - 1 Week
Follow-Up - 2 Weeks
Follow-Up - 3 Weeks
Follow-Up - 4 Weeks
Follow-Up - 6 Months
MEDICAL-SURGICAL CLEARANCE
PHYSICIAN ASSISTANT - TEDDY O. UZAMERE, PA-C
First Available (Medical-Surgical Clearance)
Follow-up - 1-Week
Follow-up - 2-Weeks
Follow-up - 3-Weeks
Follow-up - 4-Weeks
Follow-up - 10-Weeks
VEIN MEDICINE
PHYSICIAN ASSISTANT - TEDDY O. UZAMERE, PA-C
PHYSICIAN - JOHN PITMAN, MD
First Available (Vein Medicine)
Follow-up - 1-Week
Follow-up - 2-Weeks
Follow-up - 3-Weeks
Follow-up - 4-Weeks
Follow-up - 10-Weeks
Spinal Surgery
Aron Rovner, MD
Vikas Varma, MD
Gbolohan Okubadejo, MD
John Shiau, MD
First Available (Neuro/Spine Physician)
Follow-Up - 1-Week
Follow-Up - 2-Weeks
Follow-Up - 3-Weeks
Follow-Up - 4-Weeks
Follow-Up - 6-Months
Orthopaedic Sports Surgery
Aron Rovner, MD
Kevin Wright, MD
First AvDailable (Orthopaedic Sports Surgeon)
Follow-Up - 1 Week
Follow-Up - 2 Weeks
Follow-Up - 3 Weeks
Follow-Up - 4 Weeks
Follow-Up - 6 Months
Neurology
JUAN-CARLOS MARTINEZ-BARRERA, MD
Ashwin Malhotra, MD
First Available (Neurologist)
Follow-Up - 1 Week
Follow-Up - 2 Weeks
Follow-Up - 3 Weeks
Follow-Up - 4 Weeks
Follow-Up - 6 Months
Chiropractic
Altman Physical Therapy Center
Integrative Spine & Sports
Pre-Op/Pre-Admission Testing
TEDDY O. UZAMERE, PA-C
First Available (PAT Provider)
Follow-Up - 1 Week
Follow-Up - 2 Weeks
Follow-Up - 3 Weeks
Follow-Up - 4 Weeks
Follow-Up - 6 Months
Psychiatry/Ketamine
Vassilis N. Panagopoulos, MD
Grant Brenner, MD
First Available (Psychiatrist Physician)
Follow-Up - 1 Week
Follow-Up - 2 Weeks
Follow-Up - 4 Weeks
Follow-Up - 6 Months
Podiatry / Foot and Ankle Surgery
Sarah Richards, DPM
Sarah Richards, DPM
First Available (Podiatrist)
Follow-Up - 1 Week
Follow-Up - 2 Weeks
Follow-Up - 4 Weeks
Follow-Up - 3 Months
Follow-Up - 6 Months
Physical Therapy
Altman Physical Therapy Center
First Available (Physical Therapist)
Follow-Up - 1x Per Week x 12 weeks
Follow-Up - 2x Per Week x 12 weeks
Follow-Up - 3x Per Week x 12 weeks
Acupuncture
Altman Physical Therapy Center
First Available (Acupuncturist)
Follow-Up - 1x Per Week x 20 weeks
Follow-Up - 2x Per Week x 10 weeks
Psychology
Vassilis N. Panagopoulos, MD (Psychiatrist)
First Available (Psychologist)
Mahmood Mehdi Kazmi, PsyD (Ph: 718.515.4347) - [Accepts: 1199 ; CMO ; EmblemHealth ; HIP ; GHI ; Empire BCBS ; HealthFirst ; Medicare ; NYSHIP ; Montefiore ; HIP HMO Benefits Program]
Anne Fenichel, PsyD (Ph: 914.374.6359) - [Accepts: Most All Insurances EXCEPT HealthFirst]
Martin Ogulnick, PsyD (Ph: 845.565.50725 ; E: ocanewburgh@gmail.com) - [Accepts: ALL INSURANCES Except HealthFirst]
Jonathan Kent, PsyD - [Accepts: WC/NF]
Juraci Da Silva, PsyD (Ph: 646.625.9114 or 917.677.9070) - [SPANISH SPEAKING ; Accepts: WC/NF]
Adam Lynn, PsyD (Ph: 646.456.0205 ; E: manhattanpsychological@gmail.com) - [Accepts: 1199 ; CMO ; EmblemHealth ; HIP ; GHI ; Empire BCBS ; HealthFirst ; Medicare ; NYSHIP ; Montefiore ; HIP HMO Benefits Program]
Follow-Up - 1x Per Week x 12 weeks
Follow-Up - 2x Per Week x 12 weeks
Follow-Up - 3x Per Week x 12 weeks
SCS (Spinal Cord Stimulator) Psychological Evaluation
PNS (Peripheral Nerve Stimulator) Psychological Evaluation
Depression / Anxiety
TBI (Traumatic Brain Injury) Evaluation
PLASTIC SURGERY & AESTHETICS
Aesthetics
Botox
Fillers
Facials
IV Therapy
Weight Loss Injectable(s)
Follow-Up - 2 Weeks
Follow-Up - 10 Weeks
Follow-Up - 3 Months
Follow-Up - 6 Months
Follow-Up - 12 Months
Plastic Surgery
John Pitman III., MD
Syed Sayeed, MD
Karan Chopra, MD
1st Available
Weight Management
Karan Johar, MD - Semaglutide Telehealth
1st Available - Semaglutide Telehealth
DIAGNOSTIC STUDY REQUEST(S)
EMG/NCS
EMG UE #1 (UPPER EXTREMITY)
EMG UE #2 - At Least 6 Months + 1 Day After Previous EMG UE
EMG LE #1 (LOWER EXTREMITY)
EMG LE #2 - At Least 6 Months + 1 Day After Previous EMG LE
Balance Tests
TCD #1 (Transcranial Doppler)
TCD #2 (Transcranial Doppler) - At Least 12 Months + 1 Day After
VNG #1 (VIDEONYSTAGMOGRAPHY)
VNG #2 (VIDEONYSTAGMOGRAPHY) - At Least 12 Months + 1 Day After Previous EMG LE
VEIN STUDIES
PHYSICIAN ASSISTANT - TEDDY O. UZAMERE, PA-C
PHYSICIAN - JOHN PITMAN III., MD
ABI #1 (Ankle-Brachial Index)
ABI #2 (Ankle-Brachial Index) - At Least 12 Months +1 Day After Previous ABI
ARTERIAL US (Lower Extremity Arterial Ultrasound)
Arterial US #2 (Lower Extremity Arterial Ultrasound) - At Least 12 Months +1 Day After Previous Arterial US
VEIN US (Lower Extremity Venous Ultrasound)
Venous US #2 (Lower Extremity Venous Ultrasound) - At Least 12 Months +1 Day After Previous Venous US
Surgical Booking Patient Preferences
Preferred Date(s):
MONDAY - AM (MORNING)
MONDAY - PM (AFTERNOONS)
TUESDAY - AM (MORNING)
TUESDAY - PM (AFTERNOONS)
WEDNESDAY - AM (MORNING)
WEDNESDAY - PM (AFTERNOONS)
THURSDAY - AM (MORNING)
THURSDAY - PM (AFTERNOONS)
FRIDAY - AM (MORNING)
FRIDAY - PM (AFTERNOONS)
SATURDAY - AM (MORNING)
SATURDAY - PM (AFTERNOONS)
OTHER - ASK MD TO SPECIFY
Preferred Location(s):
PAMS (PARK AVENUE MEDICINE & SURGERY OBSS)
LHH (LENOX HILL HOSPITAL)
CAREWELL HEALTH MEDICAL CENTER (HOSPITAL) - NEW JERSEY
HRH (HUDSON REGIONAL HOSPITAL) - NEW JERSEY
SURGICORE - MIDTOWN SURGERY CENTER
SURGICORE - FIFTH AVENUE SURGERY CENTER
SURGICORE - EMPIRE STATE SURGERY CENTER (BRONX)
SURGICORE - NEW JERSEY - SADDLEBROOK SURGERY CENTER
SURGICORE - FLORIDA - MIAMI REGIONAL SURGERY CENTER
SURGICORE - FLORIDA - HOLLYWOOD REGIONAL SURGERY CENTER
SURGICORE - FLORIDA - PALM BEACH GARDENS REGIONAL SURGERY CENTER
BAY RIDGE SURGI-CENTER (BROOKLYN)
GRAMERCY SURGERY CENTER - 380 2nd Ave, 10TH FLOOR, NEW YORK, NY 10010
PALISADES SURGICAL SUITES - FORT LEE, NJ
OTHER SURGERY LOCATION - ASK MD TO SPECIFY VIA EMAIL
PARK AVENUE CLINIC - 993 PARK AVENUE
ENGLEWOOD, NJ CLINIC - 25 ROCKWOOD PLACE
TELEHEALTH
OTHER CLINIC LOCATION - ASK MD TO SPECIFY VIA EMAILL
Anesthesia:
LOCAL (NO ANESTHESIOLOGIST NEEDED)
MODERATE ANESTHESIA CARE (ANESTHESIOLOGIST)
GENERAL (ANESTHESIOLOGIST)
Device / Aesthetic Representatives:
SCS - Nevro - NEW YORK - Saverio Salcfas ; saverio.salcfas@nevro.com ; 908.456.4277)
SCS - Nevro - FLORIDA - Kyle Eno (Kyle.Eno@nevro.com ; 561.323.3541)
SCS - Abbott - NEW YORK - Robert Piersanti (Robert.Piersanti@abbott.com ; 973.975.8772)
SCS - Abbott - NEW JERSEY - Chris Robitaille (christopher.robitaille@abbott.com ; 860.387.3030)
SCS - Abbott - FLORIDA - Brian Richardson (brian.richardson@abbott.com ; 321.231.0185)
SCS - Boston Scientific - NEW YORK - Jared Homan (jared.homan@bsci.com ; 310.944.0104)
SCS - Boston Scientific - NEW YORK - Jill Shears (jillian.shears@bsci.com ; 610.764.9498)
PNS - Curonix - NEW YORK - Victor Milani (victor.milani@curonix.com ; 203.903.6331)
PNS - Curonix - FLORIDA - Victor Milani (victor.milani@curonix.com ; 203.903.6331)
PNS - Nalu Medical - NEW YORK - Christopher Dicks (cdicks@nalumed.com ; 718.844.4876)
PNS - Nalu Medical - FLORIDA - Ivan Roa (iroa@nalumed.com ; 786.634.8780)
MINUTE MAN - Nemi-Tech - NEW YORK - Ryan Clark (ryan.clark@nemi-tech.com ; 405.549.1611)
SI FUSION - Nemi-Tech - NEW YORK - Ryan Clark (ryan.clark@nemi-tech.com ; 405.549.1611)
VIA DISC - Nemi-Tech - NEW YORK - Ryan Clark (ryan.clark@nemi-tech.com ; 405.549.1611)
PERCUTANEOUS - ELLIQUENCE DISC FX - Percutaneous Discectomy - NEW YORK - Gus Conde (gconde@compassspine.net ; 347.729.6135)
ENDOSCOPIC - ELLIQUENCE DISC FX - Percutaneous Discectomy - NEW YORK - Gus Conde (gconde@compassspine.net ; 347.729.6135)
PRP - Plymouth Medical - NEW YORK - Andy Shepard (andrew@plymouthmedical.com ; 917.685.3187)
PRP/STEM CELL - Zimmer Biomet - NEW YORK - Nicole Maria Holzer (nholzer@zb-nyc.com ; 516.551.4471)
NEUROMONITORING - Accurate IOM - NEW YORK - Matt Kohm (mattk@accurateiom.com ; 917.952.7441)
INTERROGATION AND REPROGRAMMING SCS/PNS - SEE ABOVE FOR CORRECT REPRESENTATIVE
mild® - Vertos Medical - NEW YORK - Joanna King (jking@vertosmed.com ; 845.206.3333)
FACET SCREW FUSION - Ion Facet Screw System - Nemi-Tech - NEW YORK - Ryan Clark (ryan.clark@nemi-tech.com ; 405.549.1611)
Attorney / Paralegal Name (Must Notify if WC/NF/General Liability Case of MISSED PROCEDURES):
MISCELLANEOUS NOTES FOR SURGICAL BOOKING (Optional):
PAIN GENERATORS:
PAIN GENERATOR(S): (Check All that Apply / No Specific Order)
HEADACHES
CERVICAL FACET - LEFT
CERVICAL FACET - RIGHT
CERVICAL RADICULOPATHY
THORACIC FACET - LEFT
THORACIC FACET - RIGHT
THORACIC RADICULOPATHY
LUMBAR FACET - LEFT
LUMBAR FACET - RIGHT
LUMBAR RADICULOPATHY
LUMBAR SPINAL STENOSIS
LOW BACK PAIN (ASK MD FOR DETAILS)
SACROILIAC JOINT - LEFT
SACROILIAC JOINT - RIGHT
TAILBONE
CRPS/RSD UE (UPPER EXTREMITY) - LEFT
CRPS/RSD UE (UPER EXTREMITY) - RIGHT
CRPS/RSD LE (LOWER EXTREMITY) - LEFT
CRPS/RSD LE (LOWER EXTREMITY) - RIGHT
HIP PAIN - LEFT
HIP PAIN - RIGHT
SHOULDER PAIN - LEFT
SHOULDER PAIN - RIGHT
KNEE PAIN - LEFT
KNEE PAIN - RIGHT
MUSCLE PAIN (OFFICE ONLY)
VEINS (ASK MD FOR DETAILS)
ELBOW - LEFT
ELBOW - RIGHT
WRIST / HAND - LEFT
WRIST / HAND - RIGHT
ANKLE/FOOT - LEFT
ANKLE/FOOT - RIGHT
MALAISE / FATIGUE (ASK MD WHAT LABS ARE NEEDED)
MIS - Levels to Be Treated (VIA DISC / MINUTE MAN / PERCUTANEOUS OR ENDOSCOPIC DISC FX / PRP / STEM CELL)
MINUTE MAN - Interspinous Fusion
Percutaneous Discectomy - Elliquence
Endoscopic Discectomy - Elliquence
ION Facet Screw Fusion
MIS - Levels to Be Treated (VIA DISC / MINUTE MAN / PERCUTANEOUS OR ENDOSCOPIC DISC FX / PRP / STEM CELL)
Level / Disc @ L1-L2
Level / Disc @ L2-L3
Level / Disc @ L3-L4
Level / Disc @ L4-L5
Level / Disc @ L5-S1
Please Type In Order of Pain Generators:
SPECIAL COMMENTS / INSTRUCTIONS:
ELECTRONIC SIGNATURE SECTION:
PHYSICIAN NAME / E-SIGNATURE:
*
KARAN JOHAR, MD (PAIN MANAGEMENT)
JUAN-CARLOS MARTINEZ-BARRERA, MD (NEUROLOGY)
TEDDY O. UZAMERE, PA-C
JOHN PITMAN, MD (PLASTIC SURGERY)
ROY BERENHOLTZ, MD (ANESTHESIOLOGY)
ARIE DADUSH, MD (SPORTS MEDICINE)
RUSSELL SILVER, MD (PHYSICAL MEDICINE & REHABILITATION)
JOHN SHIAU, MD (NEUROSURGERY)
KARAN CHOPRA, MD (PLASTIC SURGERY)
Thank you!
