Electroencephalogram (EEG ) Request Form

Form Template

An EEG is a common medical test used by doctors for the diagnosis and treatment of neurological brain disorders.

5,000 Companies save time and money with GoCanvas

Lumen Logo Post Consumer Brands Logo Saluda Hill Landscapes Logo Te3co Logo Two Men and a Truck Logo VIP Lighting Logo

When a patient has had a traumatic brain injury or experiences symptoms such as syncope, suspicion of seizures or epilepsy, seizures, vertigo, memory loss, confusion or symptoms of Alzheimer's Disease, this type of testing will help identify abnormal patterns in brain activity, so doctors can identify medications or procedures necessary to help the patient. The noninvasive test involved electrodes being attached to the head of the patient to record the signals and brain activity. The test is then sent to a computer so doctors can identify the EEG abnormalities and diagnosis the problem. The Electroencephalogram (EEG ) Request Form should be used by doctors to request this testing for a patient. On the EEG request, they will need to identify the symptoms that prompted the test and select which kind of EEG testing is needed.

Features
  • Signature Capture
  • GPS
  • Image Capture
  • Conditional Fields
Read More
Platforms
  • iPhone
  • iPad
  • Android
  • Windows
Read More
Integrations
  • Quickbooks
  • Salesforce
  • Google Docs
  • Dropbox
Read More
*The Capterra SoftwareAdvice ​and GetApp logos are a service mark of Gartner, Inc. and/or its affiliates and is used herein with permission.*

Don't take our word for it...

“I’m not a tech guy and I was able to pick this thing up in probably an hour, and actually start to build apps. I’ve done them over lunch when I’ve gotten frustrated with a process that didn’t exist in our company. So for non tech people who’ve got a problem, the support here is awesome and I’d recommend it to anybody, not just in our industry.”

Dave Kramer, PennLine Service

Connect with one of our experts today.

We’ll help you put together the right solution for your needs.

Contact Us