Patient Forms PDF Print E-mail

Please print and complete the appropriate Registration form (Adult or Child), as well as the Patient Consent and Release Form listed below.  In addition, please locate any additional Health History Forms required by your doctor, and bring all completed paperwork with you to your appointment.

Patient Registration

Adult Registration Form (PDF Format)

Children's Confidential Personal Data Form (PDF Format)

Patient Consent and Release Form (PDF Format)

Adult Neurology

Ingrid Abols, M.D.

Rajiv Aggarwal, M.D.

Janiece Aldinger, M.D.

Irfan M. Altafullah, M.D.

Elias Bazakos, M.D.

Sarah M. Benish, M.D.

Ivan L. Brodsky, M.D.

Xiaoming Dong, M.D., M.Sc.

Gail Francis, M.D.

Masood R. Ghazali, M.D.

Jessica O. Heiring, M.D.

Charles H. Horowitz, M.D.

Jack E. Hubbard, Ph.D., M.D.

Bruce I. Idelkope, M.D.

Allan P. Ingenito, M.D

Moeen A. Masood, M.D.

Sotirios A. Parashos, M.D., Ph.D.

Daniel C. Randa, M.D.

Joanne B. Rogin, M.D.

Leland J.C. Scott, M.D., Ph.D.

Steven D. Stein, M.D.

John E. Trusheim, M.D.

Yelena V. Usmanova, M.D., M.Sc.

Alexander Y. Zubkov, M.D., Ph.D.

Felix Zwiebel, M.D.

Pediatric Neurology

Donald J. Chadwick, M.D.

Armantina M. Espinosa, M.D.

Allan P. Ingenito, M.D.

Rehabilitation Services

Rehabilitation

Neurodiagnostic Testing Forms

MRI Medical History Questionairre

Release of Medical Records

Release of Medical Record Procedures

Authorization for Disclosure of Medical Records Form (PDF Format)

 

 
Clinic Locations

GOLDEN VALLEY / MAIN OFFICE
4225 Golden Valley Road, Golden Valley, MN 55422
(763) 588-0661

BURNSVILLE
Oak Ridge East Professional Building
675 E. Nicollet Boulevard, Suite 100, Burnsville, MN 55337
(952) 435-8516 (Neurology services)
(952) 898-5000 (Rehab services)

COON RAPIDS
3833 Coon Rapids Blvd., Suite 100, Coon Rapids, MN 55433
(763) 427-8320

EDINA
Southdale Place
3400 West 66th St, Suite 150, Edina, MN 55435
(952) 920-7200 (Neurology services)
(952) 920-8088 (Rehab services)

MAPLE GROVE
North Memorial Medical Office
9825 Hospital Drive, Suite 103, Maple Grove, MN 55369
(763) 302-4114

OUTREACH LOCATIONS
Twin Cities Metro, Greater Minnesota & Western Wisconsin