PHYSICIAN ORDER FORM - DR. JOHAR - NYCISS - Integrative SPINE AND SPORTS

Patient Name *

First Name

Last Name

Date of Birth: (ex: Month, Day, Year: January, 01, 1990) *

MM

DD

YYYY

PAIN MANAGEMENT

KARAN JOHAR, MD

First Available (Pain Management Physician)

Follow-up - 1-Week

Follow-up - 2-Weeks

Follow-up - 4-Weeks

Follow-up - 10-Weeks

Neuro/Spinal Surgery

Gbolohan Okubadejo, MD

John Shiau, MD

First Available (Neuro/Spine Physician)

Follow-Up - 1-Week

Follow-Up - 2-Weeks

Follow-Up - 4-Weeks

Follow-Up - 6-Months

Orthopaedic Sports Surgery

Kevin Wright, MD

First Available (Orthopaedic Sports Surgeon)

Follow-Up - 1 Week

Follow-Up - 2 Week

Follow-Up - 4 Week

Follow-Up - 6 Months

Neurology

Ashwin Malhotra, MD

First Available (Neurologist)

Follow-Up - 1 Week

Follow-Up - 2 Weeks

Follow-Up - 4 Weeks

Follow-Up - 6 Months

Sports Medicine

Sonali Lal, MD

First Available (Sports Medicine Physician)

Follow-Up - 1 Week

Follow-Up - 2 Weeks

Follow-Up - 4 Weeks

Follow-Up - 6 Months

Chiropractic

Integrative Spine & Sports

Pre-Op/Pre-Admission Testing

Anjuli Cogman, MD

First Available (PAT Physician)

Follow-Up - 1 Week

Follow-Up - 2 Weeks

Follow-Up - 4 Weeks

Follow-Up - 6 Months

Psychiatry/Ketamine

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

Jason Cho, 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

Integrative Spine and Sports

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

Ah Young Chang, LAc

First Available (Acupuncturist)

Follow-Up - 1x Per Week x 20 weeks

Follow-Up - 2x Per Week x 10 weeks

Psychology

Jonathan Kent, PsyD

First Available (Psychologist)

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

Aesthetics

Botox with Dr. Sonali Lal

Fillers with Dr. Sonali Lal

Facials with Dr. Sonali Lal

IV Therapy with Dr. Sonali Lal

Weight Loss Injectable(s) with Dr. Sonali Lal

Follow-Up - 2 Weeks

Follow-Up - 10 Weeks

Follow-Up - 3 Months

Follow-Up - 6 Months

Follow-Up - 12 Months

Plastic Surgery

Karan Chopra, MD

1st Available

EMG/NCS

EMG UE #1 (UPPER EXTREMITY) with Dr. Sonali Lal

EMG UE #2 - At Least 6 Months + 1 Day After Previous EMG UE with Dr. Sonali Lal

EMG LE #1 (LOWER EXTREMITY) with Dr. Sonali Lal

EMG LE #2 - At Least 6 Months + 1 Day After Previous EMG LE with Dr. Sonali Lal

VEIN STUDIES

ABI #1 (Ankle-Brachial Index) with Anjuli Cogman, DO

ABI #2 (Ankle-Brachial Index) - At Least 12 Months +1 Day After Previous ABI with Anjuli Cogman, DO

ARTERIAL US (Lower Extremity Arterial Ultrasound) with Anjuli Cogman, DO

Arterial US #2 (Lower Extremity Arterial Ultrasound) - At Least 12 Months +1 Day After Previous Arterial US with Anjuli Cogman, DO

VEIN US (Lower Extremity Venous Ultrasound) with Anjuli Cogman, DO

Venous US #2 (Lower Extremity Venous Ultrasound) - At Least 12 Months +1 Day After Previous Venous US with Anjuli Cogman, DO

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)

HRH (HUDSON REGIONAL HOSPITAL)

SURGICORE - MIDTOWN SURGERY CENTER

SURGICORE - FIFTH AVENUE SURGERY CENTER

SURGICORE - EMPIRE STATE SURGERY CENTER (BRONX)

BAY RIDGE SURGI-CENTER (BROOKLYN)

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 - 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 - Nevro - NEW YORK - Scott Lenahan (scott.lenahan@nevro.com ; 516.243.6805)

SCS - Nevro - FLORIDA - Kyle Eno (Kyle.Eno@nevro.com ; 561.323.3541)

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 - 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)

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

PAIN GENERATOR(S):

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

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)