Ambulatory EEG w/ Video Order Form

I certify that I am referring the above-named patient for electroencephalographic (EEG) monitoring (routine EEG, 72HR ambulatory EEG with video) 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 itself provide a diagnosis nor will it recommend a therapeutic treatment for this patient.