• Epilepsy Monitoring Unit Referral Request Form

    Use this form to submit a referral for epilepsy monitoring unit evaluation and provide the clinical and scheduling details needed to process the request.

  • Patient Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Referral Source Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Clinical Referral Details

  • Approximate onset date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Prior video EEG or EMU admission

  • Scheduling and Urgency

  • Referral urgency level*
  • Preferred appointment date range*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Best days and times for contact or admission scheduling

  • Insurance and Authorization

  • Authorization / Pre-certification Status*

  • Attachments and Additional Notes

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  • Upload a File
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