EEG Consent for Procedure

Georgia Epilepsy & Neurology Institute, LLC
4275 Johns Creek Parkway, Suite C
Suwanee, Georgia 30024
Phone: 912-513-1041

MM slash DD slash YYYY
MM slash DD slash YYYY
1. AUTHORIZATION FOR PROCEDURE

I authorize the providers and clinical staff at Georgia Epilepsy and Neurology Institute, LLC to perform an Electroencephalogram (EEG), including routine EEG, sleep EEG, prolonged EEG, or video EEG monitoring as ordered by the physician. The purpose of this test is to record the electrical activity of the brain to assist in diagnosis and treatment of neurological conditions.

2. DESCRIPTION OF PROCEDURE

During the EEG, small electrodes will be placed on the scalp using paste or gel. The procedure is painless and non-invasive. The test may include routine recording, sleep recording, hyperventilation, photic stimulation, video monitoring, or prolonged recording. The patient may be asked to remain still, open and close the eyes, breathe deeply, look at flashing lights, or attempt to sleep. Video recording may be used during the EEG to help correlate physical activity with brain wave activity.

Acknowledgement of Instructions:

I acknowledge that I have been given instructions for the EEG procedure and understand that following these instructions is necessary to obtain accurate test results. I understand that I should wash my hair before the test, avoid oils, sprays, gels, or conditioners, continue medications unless instructed otherwise, avoid caffeine if possible, follow sleep instructions if ordered, arrive on time, and follow all staff instructions. Failure to follow instructions may affect the quality of the test and may require the procedure to be repeated.
3. RISKS AND POSSIBLE COMPLICATIONS

EEG testing is considered safe. Possible risks include mild skin irritation, temporary redness, discomfort, fatigue, anxiety, and rarely seizure activity. Staff are trained to respond to any event.

4. CONSENT FOR EMERGENCY CARE

If a seizure or medical emergency occurs during the EEG, I authorize the medical staff to provide appropriate treatment including emergency care if necessary.

5. PEDIATRIC CONSENT

For patients under 18 years of age, I certify that I am the parent or legal guardian of the minor listed above and have legal authority to consent for medical care.

6. CONSENT FOR VIDEO / AUDIO RECORDING

I understand that video and/or audio recording may be used during EEG monitoring for diagnostic purposes and will become part of the medical record.

7. CONSENT

I have read or had this form explained to me. I understand the  procedure, risks, benefits, and alternatives and voluntarily consent to the EEG procedure.

8. WITNESS / STAFF

Staff signature below confirms consent was obtained.
Clear Signature
Clear Signature
Clear Signature