EEG Monitoring Request

Please use the form below to request an EEG.

You can also download the form in .pdf if you want to print and fill it out by hand. Please return the completed form to: info@nyota-tano.com

Click to download form

 

request EEG

Please fully complete the form below and we will be in touch shortly.

EEG Request

EEG Options

Patient Information

Address
Address
City
State/Province/Parish/Region
Zip/Postal
Country
Gender

Referring Physician

Address
Address
City
State/Province/Parish/Region
Zip/Postal
Country
I certify to the best of my knowledge that this test and any interpretation is medically necessary in order to diagnose my patient. I understand that this test and any interpretation provided are intended only to supplement my diagnosis of this patient’s condition. I recognize that Nyota-Tano Diagnostics will not provide a diagnosis of this patient nor will Nyota-Tano Diagnostics Ltd. recommend any therapeutic measures for this patient.
Start Over

Passionate about Your Community

We are creating an extensive team of trained professionals throughout the Caribbean to meet your needs. Click below to find a local provider…

Search Now