My signature on this form indicates that: (1) I have read and understood the information provided in this form; (2) I have been provided with the opportunity to ask and receive answers to any questions I have about the Procedure; and (3) I authorize and consent to the performance of the Procedure by California Diagnostic Specialists, Inc. (CDS) physicians/staff.

Electromyography (EMG)

Electromyography (EMG) is a diagnostic procedure to assess the health of muscles and the nerve cells that control them (motor neurons). EMG results can reveal nerve dysfunction, muscle dysfunction or problems with nerve-to-muscle signal transmission.

Motor neurons transmit electrical signals that cause muscles to contract. An EMG uses tiny devices called electrodes to translate these signals into graphs, sounds or numerical values that are then interpreted by a specialist.

During the procedure, a needle electrode is inserted directly into a muscle and records the electrical activity in that muscle. The skin is cleansed with an alcohol wipe and then the needle is inserted into the relaxed muscle to be evaluated. You may feel a pinch or a sting as the needle is inserted through the skin. When the needle is inside the muscle you may feel a pressure or discomfort. This is necessary to assess the ability of muscles to respond to nervous stimulation. The test will record muscle activity and can be heard as static on the EMG machine. You will be asked to tighten your muscles to also evaluate them at work.

EMG is a low-risk procedure and complications are rare. There is a small risk of bleeding, infection and nerve injury where a needle electrode is inserted.

Nerve Conduction Study

A nerve conduction study (NCS), also called a nerve conduction velocity (NCV), measures how fast an electrical impulse moves through your nerve. It can identify nerve damage. During the test, your nerve is stimulated using electrode stickers applied to the skin (surface electrodes). One electrode stimulates your nerve with a very mild electrical impulse. The other electrode records it. The resulting electrical activity is recorded by another electrode. This is repeated for each nerve being tested. Mild electrical currents are delivered as a brief electric shock. The amount of the electrical current is always kept at a safe level. You will feel a tingling sensation and your muscles will twitch as the current flows from the point to the recording electrodes. It will be measured and recorded on the EMG machine. The test will not harm you but may be painful.

Certain factors or conditions may interfere with the results of the NCV tests. This includes damage to the spinal cord, severe pain before the test, and body temperature. You need to inform your physician if you have a cardiac defibrillator or pacemaker, as precautions may need to be taken.

There will be no restrictions on your activity after the tests. At times you may experience some minor aches or discomfort. If so, take it easy that day. There is a slight risk of bleeding or infection at the electrode sites. If you notice any bleeding, increase in discomfort or signs of infection such as redness, warmth, swelling, pain, drainage or fever > 101 degrees F, please call your physician immediately.

Authorization and Consent

1. I have been informed and acknowledge that I am free to obtain an EMG and NCS from the provider of my choice. I have decided that I would like to have the EMG and NCS performed by CDS.
2. I hereby authorize and direct CDS physicians/staff to perform the EMG and NCS (the “Procedure") and to perform any other diagnostic procedure and therapeutic procedure that their judgment may dictate to be advisable in case of emergency.
3. I acknowledge that CDS physicians/staff have fully explained to me the nature and purpose of the Procedure and that the Procedure may involve calculated risks of complications and injury from both known and unknown causes, including but not limited to bruising, bleeding, nerve damage, worsening pain, or infection. I acknowledge that no warranty or guarantee has been made as to the results or cure regarding any ailment I may have. I acknowledge I have been informed of the nature and purpose of the Procedure, the expected benefits, the risks of the complications, and the alternative methods of treatment, if applicable.
4. I recognize that I have the right to consent to or refuse the proposed Procedure after consultation with CDS physicians/staff. Further, I recognize that this form is not intended to be a substitute for the explanations of the nature and purpose of the procedure, the expected benefits, the risks of complication, and the alternative methods of treatment, if applicable, which have been explained to me by CDS physicians/staff.
5. I hereby authorize and direct CDS to provide such additional services for me as deemed reasonable and necessary.
6. I hereby authorize CDS to release my medical records to my referring doctor. Your EMG/NCV report will be forwarded to your referring physician within 72 hours. Your referring physician will go over the test results with you and should be able to provide you a copy of your report, upon request. If you would like a copy of your EMG/NCV report sent directly to you from our office, please call our office 72 hours after the date of service.
7. I may choose to have CDS’s on-site assistants help fill out my patient intake forms. I acknowledge that, depending on circumstances, this conversation may or may not be private and confidential, and that by so requesting assistance, I waive any confidentiality protection related to my personal health history. I understand that if I do not wish to waive these rights, I can complete the patient forms without CDS assistance. (NOTE: The below paragraph does NOT apply if you are a workers’ compensation patient.) I understand, acknowledge and agree that I am financially responsible for any portions of the fees for services not paid for by my insurance company, including my deductible, co-insurance and any amount exceeding what my insurance company pays, except where exempt by contractual agreement. I further understand that I am responsible for complying with any requirements that my insurance carrier may have regarding referrals, prior approvals, pre- authorizations and second opinions, and that my failure to fully comply with my insurer’s requirements may result in the denial of the claim(s) related to the services being provided, and in such instance I am fully responsible to pay.

I HAVE READ THE ABOVE AUTHORIZATION AND ACKNOWLEDGEMENT AND IT HAS BEEN FULLY EXPLAINED TO ME. I CERTIFY THAT I UNDERSTAND THE CONTENTS OF THIS FORM, THAT I HAVE BEEN PROVIDED THE OPPORTUNITY TO ASK AND RECEIVE ANSWERS TO ANY QUESTIONS I HAVE CONCERNING THE PROCEDURE, AND THAT I AM COMPETENT TO EXECUTE THIS CONSENT OR THAT I AM AUTHORIZED TO EXECUTE IT ON THE PATIENT'S BEHALF.