EEG/EKG Test Order Form
Complete this form to request and process an EEG or EKG diagnostic test order.
Patient Information
Patient Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
*
Phone
Email
Text Message
Other
Referring Provider / Facility Information
Referring Provider Name
*
First Name
Middle Name
Last Name
Clinic / Facility Name
*
Provider Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Provider Email
example@example.com
Order / Reference Number
Test Details
Requested Test Type
*
EEG
EKG
Both EEG and EKG
Other
Requested Test Date or Preferred Date Range
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Urgency / Priority
*
Please Select
Routine
Urgent
STAT
Other
Preferred Facility / Location
Clinical Information
Reason for test / clinical indication
*
Symptoms or concerns
Chest pain
Shortness of breath
Palpitations
Dizziness
Syncope (fainting)
Seizure activity
Headache
Weakness
Tremor
Other
Relevant medical history and current medications or treatments
Special instructions for the lab
Order Processing Details
Insurance Provider
Please Select
Not Provided
Blue Cross
Aetna
Cigna
UnitedHealthcare
Medicare
Medicaid
Other
Member / Policy ID
Scheduling / Urgency / Follow-up Notes
Submit Order
Should be Empty: