Patient First Name

Patient Last Name

Date of Birth

Social Security Number

Address

Mailing Address

City

State

ZIP/Postal Code

Cell Phone Number

Other Phone Number

Insurance Name

Policy ID#

Group #

Referring Provider Last Name

Referring Provider First Name

Referring Provider Phone Number

Referring Provider Fax Number

Medically Stable?

YesNo

Clinical Diagnosis

Reason for Referral

Does the patient have known seizures?

YesNo

Admission for medical adjustment

YesNo

Evaluate for Epilespy surgery

YesNo

Please fax H&P, EEG/MRI/CT reports, most recent telephone notes, and most recent clinic notes. Clinical documentation required.

Fax to: Epilespy Monitoring Unit: 205-975-6360
Please call with any questions: 205-934-6418/205-934-6511