Epilepsy Monitoring Unit Admission Request

University Medical Center of El Paso Epilepsy Monitoring Unit Admission Request In conjunction with Texas Tech Physicians (Neurology)

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Neurology EMU Admission Request

Date

UMC MRN#

*Patient Name

Date of Birth

Patient phone number

Person to call to schedule

(if other than patient)

Contact phone number

(if other than patient)

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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