Request an Evaluation

Basic Information

Tell us a little about yourself so our team can contact you and begin reviewing your information.

Full Name*

Phone Number*

Email Address*

City / State / Country*

Preferred Contact Method

Phone

Email

Telemedicine

Best Time to Contact You

Morning (8am–12pm)

Afternoon (12pm–5pm)

Evening (5pm–8pm)

No preference

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Condition & Symptoms

Help us better understand the symptoms or condition for which you are seeking evaluation.

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Treatment History

This information helps us better understand your treatment history and determine what additional evaluation may be helpful.

Your care team

If you have these to hand, they let us request your records and keep the doctors already involved in the loop. Every field here is optional.

Primary care physician

Their phone number or email

Referring neurologist

Their phone number or email

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Goals & Logistics

Every patient's goals are different. Understanding what matters most to you helps guide the evaluation process.

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Your Story

In your own words, tell us how your symptoms affect your daily life and what you are hoping to improve.

Describe how your symptoms affect your day-to-day activities, quality of life, work, hobbies, independence, or goals

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Records and Imaging

There is nothing to attach here — records and images reach RUSH through a secure upload portal rather than through this form. This is what we will ask for and how each piece gets to us, so you can send it now if you would like to.

Brain imaging

We need the MRI or CT images themselves, not only the radiologist's report. RUSH receives outside studies through Ambra, a secure medical image exchange, and you can send yours now rather than waiting to be asked: open the secure upload portal, enter your email address to sign in or create an account, choose Upload Imaging and select the disc or the folder of images.

If the study was done at a hospital already on the Chicago-area Ambra network, their radiology department can send it straight to RUSH instead; ask them to. A disc mailed to the program works too. Step-by-step upload instructions cover records as well.

Clinic notes and prior testing

Notes from your neurologist, results of previous testing and a current medication list. Your coordinator sends a records release to sign and then requests these on your behalf, so you do not have to chase them yourself. If you already hold copies, the same portal takes them — choose Upload Files/Documents rather than imaging.

A short video, if you have one

Symptoms are rarely at their most typical in a clinic room, so a brief phone video — pouring a drink, writing, walking — is genuinely useful. There is no video upload yet, so bring it to the visit or ask your coordinator where to send it.

Please do not email records, images or video to us unprompted. Ordinary email is not a secure channel for health information, which is exactly what Ambra and MyChart exist to solve.

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What Happens Next