Name *

First Name

Last Name

Phone *

(###)

###

####

Do you Reside in the USA? *

*All physicians must reside in and read from within the USA

Yes

No

What credentials do you have? *

*Must have at least one board certification to be eligible for an interview

ABPN with special qualification in Clinical Neurophysiology

ABPN with special qualification in Epilepsy

ABCN

Other

Are you comfortable reading both adult and pediatric/neonatal EEGs? *

*At this time we require our physicians to have experience reading EEGs in all patient populations (neonates, pediatrics, and adults).

Yes

No

Would you be available for 1-2 weeks on-call coverage per month? *

*We require our physicians to take a minimum of at least 1 week of on-call per month (Mon-Sun)

Yes

No

What Fellowship Training have you completed? *

*Must have completed fellowship to be eligible for an interview

Epilepsy

Clinical Neurophysiology

Other