qEEG COVER SHEET
Q-Metrx, Inc.
1612 W. Olive Avenue, Suite 301
Burbank, CA 91506
(818) 563-5409
Fax: (818) 842-2043
Email: info@q-metrx.com
www.q-metrx.com
PATIENT INFORMATION:
Name: Test Date: ID#
Sex: Male Date of Birth: Handedness: Right
Referring Clinician:
Complaint:
Medications:
Comment:
SERVICES REQUESTED:
Effective 03/22/2011
Ver. 1.8
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Reports with Medical Interpretation
Full qEEG - Analysis with medical interpretation of EEG and qEEG (recommended when
billing third party insurance). Topographic analysis including: current source density,
multivariate connectivity (Hudspeth), NxLink database comparison. Review of report
format is available for new users (Telephone consults: 20-30 minute).
Estimated turn around time*: 10 business days.
Brief qEEG - Analysis with medical interpretation of EEG (no medical review of qEEG
analyses). Topographic analysis including: current source density, multivariate
connectivity (Hudspeth), NxLink database comparison. Review of report format is available
for new users (Telephone consults: 20-30 minute).
Estimated turn around time*: 7 business days.
SUPER Q - Includes full qEEG analysis using NxLink database, with added sLORETA
and 1 Hz bin analyses from NeuroGuide for Linked Ears and Laplacian montages, medical
interpretation, topographic maps, multivariate connectivity analysis (Hudspeth), and
difference maps for eyes open compared to task, spectral variability mapping. Review of
report format is available for new users (Telephone consults: 20-30 minute).
Estimated turn around time*: 10 business days.
Medical Interpretation of EEG only.
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* NOTE: The turn-around times are a best estimate, but actual time to complete reports depends on
the number of qEEG reports being processed. If a report is needed urgently, please provide the latest
date the report is needed and we will make every attempt to return reports in a timely manner.
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Rapid Reports
Rapid Reporting 1 - qEEG analysis with NxLink, NeuroGuide, and a brief technical
report with recommendations for Neurofeedback training. Estimated turn around time: 5
business days.
Rapid Reporting 2 - qEEG analysis with NxLink, NeuroGuide, and MD Interpretation of
EEG only. Estimated turn around time: 3 business days.
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PRE vs. POST Reports
Brief Pre-Post Treatment Tracking Evaluation - Includes topographs and NxLink
database comparison for post recording to track effects of treatment, difference maps to
show changes between pre and post recordings and Hudspeth Connectivity analysis. No
interpretation provided. Estimated turn around time: 2 business days.
Full Pre-Post Treatment Tracking Evaluation - Includes medical interpretation of EEG
and qEEG with commentary on changes between pre and post recordings, topographs and
NxLink database comparison for post recording to track effects of treatment, difference
maps to show changes between pre and post recordings, and Hudspeth Connectivity
analysis. Estimated turn around time: 10 business days.
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Add-on Analyses to Full qEEG or BRIEF qEEG report or Stand Alone Analyses:
Data/Report Retrieval
LORETA Add-on
LORETA Stand Alone
NeuroGuide Add-on: database report, EC, EO, linked ears, Laplacian
NeuroGuide Stand Alone: database report, EC, EO, linked ears, Laplacian
NxLink Stand Alone: database report, EC, linked ears
Hudspeth Connectivity Analyses Add-on
Hudspeth Connectivity Analyses Stand Alone
(TBI) Head Injury Discriminant Analyses
Task Analysis: Add spectral analysis and topographic mapping of recordings during performance
of tasks. Please specify: Reading Math Other
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Neurofeedback Recommendations for FULL QEEG Reports* (Choose One):
Joy Lunt, R.N., BCIA, Jack Johnstone, Ph.D., QEEGD
*These fees apply only to neurofeedback recommendations based on the "FULL QEEG" and
"FULL PRE-POST" analysis reports described above. Recommendations may be provided as a
written document or telephone consultation. Additional clinical information may be requested.
Note that panel members also are available for extended case consultation for an additional fee.
Please contact Q-Metrx to make arrangements for additional consultation (818) 563-5409, or email
info@q-metrx.com.
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Other Services:
Technical Review of Raw EEG Data.
Review and interpretation of NeuroGuide, Loreta and other report formats with
Neurofeedback recommendations
Specialized Reports for Legal, Psychological, or Educational Professionals
Hardcopy and Overnight Courier
Hardcopy Raw EEG files: per 20 minute record
Extended Case Consultation or “mentoring/supervision”
Subscription Purchases
RUSH 72 hour handling on qEEG reports with medical interpretation.
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METHOD OF PAYMENT:
Payment is due prior to Q-Metrx returning the completed report unless other arrangements are made
in advance:
Select: Credit Card Check
For all Credit Card payments, a signed authorization is required. The Credit Card Consent Form, found
on the Q-Metrx website, needs to be filled out, signed and faxed to 818-842-2043.
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SENDING EEGs and RECEIVING Reports
EEG files may be transmitted to our HIPPA compliant FTP server (https://qeeg.q-metrx.com), sent on
CD or other removable media. Contact Q-Metrx for additional instructions if necessary.
When recording EEG files, be sure to indicate by labeling “eyes closed”, “eyes open”, and/or a
“specific task”. If necessary, please refer to our EEG Recording Protocols document on our website at
www.q-metrx.com.
Reports are returned in PDF format; requires free Adobe Acrobat Reader to display and print (available
at www.adobe.com). Reports are returned to the FTP server, or may be sent as password protected
encrypted email attachments (requires WinZip for decompressions and decrypting). Note that hardcopy
of reports and overnight courier is $50 per case.
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Additional information about client or recording:
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