Study Referral Form - Wadsworth Center Page 2
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1
2Does the patient have a Vagus Nerve Stimulator (VNS)?
YES o NO o
If so, have the settings been stable for at least 3 months?
YES o NO o
Is the patient on a ketogenic diet?
YES o NO o
If so has it consisted of a stable ratio for at least 3 months?
YES o NO o
Will the patient be able to travel to the study site for clinical visits?
YES o NO o
YES o NO o
Is a daily seizure diary being maintained for the patient?
(a 30 day seizure diary for review by the Principal Investigator is required at the time of clinical evaluation)
P REFFERED S TUDY L OCATION ( Choose o nly o ne)
New York Langone Medical
Mount Sinai o
Montefiore ¨
U. Rochester ¨
U. Buffalo ¨
Center o
(Dr. Orrin Devinsky)
(Dr. Harriet Kang)
(Dr. Sheryl Haut)
(Dr. David Wang)
(Dr. Arie Weinstock)
FAX referrals:
(585) 276-2970
Maria Hopkins, RN
Pediatric Neurology
Sheryl Haut, M. D.
U. of Rochester Medical
Mary Jo Elgie
Senior Research Coordinator
Suite 102
Montefiore Medical Center
Center
Women & Children’s
th
NYU Comprehensive Epilepsy
141 South Central Ave
111 East 210
St.
Child Neurology
Hospital of Buffalo
Center
Hartsdale, NY 10530
Bronx, NY 10467
601 Elmwood Avenue,
Department of Neurology
223 E 34th St.
Room 5-5517
Room 762
New York, NY 10016
Box 631
219 Bryant Street
Rochester NY 14642
Buffalo, NY 14222
Attn: Amy Vierhile
REFERRING P HYSICIAN A TTESTATION
o I certify that I am the primary neurologist responsible for directing the treatment of this patient for his / her seizure
disorder and the information provided herein is true and accurate to the best of my knowledge.
o I certify that I have discussed the clinical study with the patient and/or their parent(s)/legal guardian (as appropriate).
He/she/they have agreed in principle to participate if chosen but understand they will have the opportunity to further
discuss the study with the Principal Investigator and if selected will need to provide written consent, as administered by
the study site, to participate in the study.
o I certify that I have obtained and retained written permission from the patient and/or their parent(s)/legal guardian (as
appropriate) to forward a study referral form to the chosen epilepsy center and to forward to the NYS Department of
Health, de-identified information that will be used to randomly select patients for this study. Such data is to consist of the
last four numbers of the patient’s social security number, the patient’s gender and year of birth as well as the requested
study site.
Signature:
__________________________________________________________________________
Date:
___________________
Note: This form is to be submitted to one clinical site only (see above for addresses). Do NOT send this referral form to
the NYS DOH.
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