Referral Order Options

We have provided a Neurodiagnostics Video EEG Certificate of Necessity to be used when referring patients.

As a provider, you can easily use our secure, online HIPAA-compliant referral form, or download our Blank Referral Form.

Online Fillable Referral

Use this HIPAA secure, encrypted online form to easily send referral information.

Blank PDF Referral Form

After printing, fill out the form and fax to 972-502-9208.

Fillable PDF Referral Form

Fill out the form, print and and fax to 972-502-9208.

Required information for each patient referral:

When a Routine EEG is needed prior to completing the ordered Ambulatory EEG, we can assist with completing the Routine EEG.

NOTE: If a Routine EEG is needed, and you would like it to be done by Neurovative, you can check the Routine EEG box on the referral form in addition to the Long Term EEG before it is sent to us OR we will need a separate order if the Long Term EEG referral has already been sent.

For help on instructions or to order a set of referral forms, please contact our office by phone 281-942-0932 or email

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