Neurology Ambulatory EEG Request

University Medical Center of El Paso Ambulatory EEG Request In conjunction with Texas Tech Physicians (Neurology)

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Neurology Ambulatory EEG Request

Date

UMC MRN#

*Patient Name

Date of Birth

Patient phone number

Person to call to schedule

Contact phone number

Name of Neuro MD

Name of Personal Care Physician

*Description of events

*Frequency of events

*Current anti-seizure meds

*Outpatient EEG/result

*Imaging/results

*Reason for admission

Characterization of seizureEvaluate for Epilepsy surgeryEvaluate for subclinical seizuresSuspected psychogenic eventsOther:

Concerns/Notes

Referrring MD

Referral Date

Office contact name

Office Phone

Office Fax

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