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REFERRAL

REFER A PATIENT

Referring to Brainwave Solutions is fast and secure. Our online referral form streamlines patient submissions, making the process effortless for your staff.

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After submission, we handle insurance verification, scheduling, and patient coordination. Your patients receive hospital-grade in-home EEG testing, with detailed reports delivered within 24–48 hours.

Patient Demographics

Gender
Multi-line address
Date of Birth
Month
Day
Year

Clinical History

Medically Necessary Diagnosis Codes

Order

EEG Duration
Previous (if applicable, check all that apply)
Results

If no previous REEG is listed above OR one is listed and the results are not provided, I understand a Routine EEG will be performed prior to the AEEG and, under those circumstances, I am specifically ordering the Routine EEG to be performed prior to the Ambulatory EEG. *Please provide results for previous test(s).

Ordering Healthcare Provider

Healthcare Provider Name

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