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Steps Prior to Your
Stimulator Trial

Prior to proceeding with the stimulator trial, there are several steps that one must complete. This pre-procedural paperwork is required for authorization from insurance, your physician performing the trial, and the anesthesiologist on the day of the procedure.

These steps must be completed in order to undergo the trial and implant procedure. These items are necessary for any type of implantable therapy, including dorsal root ganglion, spinal cord stimulation, and intrathecal drug delivery systems.   

Pre-Operative Checklist

This checklist encompasses the steps and documentation required to proceed with the trial and implantation of neuromodulation therapies.  Please review the checklist and make sure to get the required paperwork completed prior to your trial.

For the trial/implant:

    □ Psychological clearance instructional sheet and sample letter- this will need to  be completed before a request for the stimulator can be placed.

    □ Medical Clearance form, if you do not have one on file with us already

    □ Request to hold blood thinners form, if needed


Precautions and instructions:

    □ Nasal testing for Staph aureus (MRSA) form and related documents if positive

    □ Pre-trial and Post-trial instructions

These documents should be reviewed and discussed with your physician or health care provider. You may not need all the forms and your physician or health care provider will let you know which forms you will need.

Medical Clearance and Hold Blood Thinners Forms

A medical clearance must be obtained prior to your trial of neuromodulation. Although these procedures are often performed under mild sedation, it is important for the team to have a full understanding of your health.

If you are taking a blood thinner you are going to have to discuss holding these medications for the procedure with the provider who is prescribing them.

You can click on the documents and download them for signature.

Psychological Clearance

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A psychological clearance is required by all insurances prior to consideration of neuromodulation. This step allows your doctor to know of any underlying psychological issues that would not make you a good candidate for this treatment, or if identify problems that can be treated beforehand.

If you need assistance locating a psychological provider who can complete this evaluation, please speak to your SPNY provider. Our team has established  psychological providers who can complete this requirement in an efficient, cost effective manner, many times over telemedicine.

Click on the hyperlink to the right for a list of providers who our team has worked with in the past and can perform the required psychological clearance. 

Pre-procedural Testing : Staph Aureus /  MRSA

Our skin contains tiny organisms that live on it naturally. Certain organisms are related to infections post operatively, and therefore it has become the standard to test for staph aureus and methacillin-resistant staph aureus. 

Treatment for a positive nasal swab for these organisms is performed with a nasal antibiotic and a scrub for the surgical site to be performed the evening before your procedure. 

Documents for treatment of a positive nasal swab can be found here.

This consent to MRSA and MSSA testing describes why we are performing this test and how it should be treated.

The day of your procedure:
Pre and Post Procedural Instructions

What next?

The approval process can only begin once the psychological clearance is completed and returned to us.


Once the required paperwork above is completed, it will be forwarded to your physician and the intraoperative team.

You can submit paperwork on Klara, our messaging service, bring it to the office, or email it to

Once the medical clearance forms are returned, the intraoperative team will review them, and you will be then scheduled accordingly.

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