REFERRING PHYSICIAN STATEMENT

• I certify that I am referring the above named patient to Seizure Diagnostics Pte Ltd for a Home VEEG services

• I certify to the best of my knowledge that the above information is accurate and true

• I understand this test and its interpretation are medically necessary in order to make a diagnosis for this patient

• I understand thatSeizure Diagnostics Pte Ltd will not provide emergency medical assistance nor recommend any therapeutic treatment for this patient