Sentient Medical Systems

Scheduling Services

Patient Information

We encourage you to use the following form to email your scheduling request. However, you may also download the Intraoperative Monitoring Form or the NeuroCare Diagnostic Form to print, fill out, and fax to us.

Intraoperative Monitoring

NeuroCare Diagnostic Test

Patient Last Name *	Patient First Name *
Date of Birth format: mm/dd/yyyy	Gender
Social Security Number * Please use this format: 123456789 (No hyphens)	Address *
City *	State *
Zip * Please enter your five digit zip code in this format: 00000	Phone * Please use this format: 000-000-0000

Hospital Information

Hospital Facility *	Surgeon/Physician *
Surgical Procedure/Level *
Surgery/Test Date * format: mm/dd/yyyy
Procedure Notes
Diagnosis Codes *
Start Time *	Duration * Duration in hours, ex. 3.5 for 3 and a half hours
Diagnosis Notes
Test Required * Test Required Test Required Other (Please Specify):
Test Notes

Patient Insurance Information

Number of Insurance Carriers * If there is more than one, please complete additional forms as needed. If you have a face sheet or copy of the insurance card please fax those as well.	Insurance Carrier *
INS ID # *	Group Name
GRP #	Phone Number * Please use this format: 000-000-0000
Address	City
State	Zip Please enter your five digit zip code in this format: 00000
Relationship to Insured * Self Spouse Child Other
Last Name	First Name
Social Security Number Please use this format: 123456789 (No hyphens)	Phone Number Please use this format: 000-000-0000
Address	City
State	Zip Please enter your five digit zip code in this format: 00000

If the patient is not the policy holder, please complete the
following information for the policy holder.

Last Name	First Name
Date of Birth format: mm/dd/yyyy	Gender
Social Security Number Please use this format: 123456789 (No hyphens)	Address
City	State
Zip Please enter your five digit zip code in this format: 00000	Phone Please use this format: 000-000-0000

Accident or Job Related Information

Injured on Job
Date of Injury format: mm/dd/yyyy	Employer
Motor Vehicle Accident
Date of Accident format: mm/dd/yyyy	Accident Claim Number

Contact Information

Name of Person Completing This Form *	E-mail Address *
Phone * Please use this format: 000-000-0000	Fax Number * Please use this format: 000-000-0000
Physician Name *	Physician UPIN Number *

* This statement will serve as a Certification of Medical Necessity. Neuromonitoring tests must be authorized. Checking this box, affirms that the doctor responsible for the above named patient’s care has authorized intraoperative monitoring using the testing modalities indicated from Sentient Medical Systems on the date specified above.