New Account Registration

  • Distributor Information

  • Practice Information

  • Provider Information

  • Order Information

  • Attestation

  • Physician Statement: I/we certify that I/we am/are referring patients for long-term electroencephalographic (EEG) monitoring, or video long-term EEG monitoring as listed above, and to the best of my knowledge this test is medically necessary in order to diagnose the patient. I understand that the diagnostic testing provided will not provide a diagnosis nor will it solely recommend a therapeutic treatment for this patient.
  • Date Format: MM slash DD slash YYYY