Name *

First Name

Last Name

Phone *

(###)

###

####

What credentials do you have? *

*Must have at least one board certification

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? *

Yes

No

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

Yes

No

What Fellowship Training have you completed? *

*Must have completed fellowship to be eligible for interview

Epilepsy

Clinical Neurophysiology

Other