Order your test

This form is for patients working with attorneys. If you are a person not working with an attorney but are experiencing symptoms, or if you are a doctor recommending a test, please give us a call at 559-599-5629 and we will give you a call back at our earliest convenience.

Thank you!

.
ATTORNEY CONTACT INFORMATION






PATIENT CONTACT INFORMATION
Patient First Name:
Patient Last Name:
Patient Email:
Patient Phone:
Patient Street:
Patient City:
Patient State:
Date of Birth:
Date of Injury:
Sex Assigned at Birth:

I request that Dr. Mikel Meyer perform a telephone consultation to help determine if a Cognition EEG/ERP test is necessary. I understand that there is a $150 fee for this consultation.

Alternatively, if a doctor has already done a consultation with the patient, please provide their contact information below.

Referring Doctor Name:
Referring Doctor Email:
Referring Doctor Phone:


Need to send additional documents to the team, please use the button on the right.

Send additional documents