NPH Referral Form

The Henry Ford Multidisciplinary NPH Program provides coordinated care across specialties for optimal evaluation and treatment of patients suspected of having Normal Pressure Hydrocephalus (NPH).

Please take 3-5 minutes and fill out the screening tool and fax it to Attention: Toni/Carol at 248-661-7390. It may be returned by email within the Henry Ford Health System to: NPHClinic@hfhs.org. For questions, phone: (248) 325-0019.

The screening tool will be reviewed within 24-48 hours by one of the nursing staff. Imaging will be obtained, and the patient/caregiver will be contacted. Once imaging and medical records are received the patient will be presented at the NPH MDC Conference.

The NPH Evaluation appointments are 2-3 hours long, which includes Neurological exam, formal cognitive testing, and ambulatory/gait evaluation.

The results of the evaluation will then be reviewed by our multidisciplinary team at the weekly NPH MDC Conference. The referring physician will receive a copy of the NPH MDC notes with the recommendations.

We provide all pre-operative, post-operative, and shunt programming care for your patients.

If you have any questions about NPH or surgery (shunting or endoscopic third ventriculostomy) please feel free to contact the RN Coordinator at: NPHClinic@hfhs.org or NPH Clinic at 248-325-0019.

NPH MDC Conference is held every Wednesday at 1:00 PM.

Participants:
Dr. Marina Novikova, Neurologist
Dr. Jason Schwalb, Neurosurgeon
Dr. Pouya Entezami, Neurosurgeon
Dr. Brent Funk, PhD, Neuropsychologist
Jennifer Kuc, Nurse Practitioner, Neurology
Carol Paine, Registered Nurse
Toni Casey, Registered Nurse, Nurse Coordinator

Dr. Novikova and either Dr. Schwalb or Dr. Entezami will participate during every conference.

Important notes regarding the referral form (below):

• Patient Insurance: Please fax demographic and insurance information to 248-661-7390 attn: Toni/Carol.
• Please order the following lab work for your patient to be completed along with your referral and fax the results to 248-661-7390 ATTN Toni/Carol: UA, CBC, Comprehensive Metabolic Profile, Mg, Phosphorus, TSH, B12, Calcium -ionized, Hemoglobin A1C, Homocysteine, Methylmalonic Acid and Vitamin D.
• If imaging is not completed, please obtain the following:
  • MRI brain without contrast
  • MRI cervical spine without contrast
  • If unable to have an MRI (e.g., shrapnel, pacemaker), please obtain a CT and CT c-spine.
• Feel free to contact us with any questions or concerns; otherwise, please submit your information to: NPHClinic@hfhs.org.