To request a consultation with the Epilepsy Center at Hartford Hospital, complete the Online Consultation Request Form below.

If you would rather complete a paper consultation request form, download the form (MS Word or PDF format) and fax the completed form to 860-545-5003.

For consultations via telephone please call 860.545.3621 EXT. 5



Online Consultation Request Form

Please note the following:

  • This form is to be completed by a referring physician.
  • A representative from the Epilepsy Center will contact you within one business day.
 
(* = Required)
 Patient Information
* Patient Name:
* Date of Birth:
 Address: Street 1
  Street 2
  City      
  State       Zip
  Country
Work Phone:
Home Phone:
Cell Phone:
Primary Insurance:
  Policy # Group #
Secondary Insurance:
  Policy # Group #
 Consultation Requested

 Consultation Includes:

  • An outpatient evaluation with a neurologist who is an epilepsy specialist.
  • When appropriate, the epilepsy specialist will order additional diagnostic testing which may include routine, extended ambulatory, or inpatient video EEG studies as well as brain imaging.
  • In many cases, psychological evaluation, neuropsychological screening, and other support services are included in our comprehensive evaluation.
  • Results of all of our assessments and recommendations will be communicated with your office and other providers as requested on this form.

Reason for Consult:

Establish a diagnosis of epilepsy versus other condition.

Known epilepsy, 2nd opinion related to epilepsy management.

Medically intractable epilepsy, evaluate other treatment options including: medications, surgery, or vagal nerve stimulator implantation.

Other:

 

Reason for Urgent Consult:

Pregnant or trying to become pregnant.

Frequent hospitalizations or ED visits for seizures.

Seizures or Spells occurring at least once a week.

Other:

* Clinical history or relevant information/question to be answered by an epilepsy specialist:

  

 Requesting Physician Information
* Physician Name:
Practice Name:

 Address: Street 1
  Street 2
  City      
  State       Zip
  Country
* Practice Phone:
Practice Fax:
Practice Email Address:
* Preferred Means of Communication: Phone   Fax   Email
 Submit Your Request


Enter code shown above:
   

 




After submitting this form, please make sure to fax the following information to 860-545-5003:

CD's or documents can also be mailed to:

Hartford Hospital Department of Neurology
80 Seymour Street.
P.O. Box 5037
Hartford, CT 06102
Attn: Epilepsy Monitoring Unit