This short questionnaire helps us understand if the epilepsy care center we are developing may be right for you or your loved one.
Who is this form about?
*
Myself
I am a caregiver for someone with seizures
Other
About how many anti-seizure medications have been tried so far?
*
None
1 anti-seizure medication
2 anti-seizure medications
3+ anti-seizure medications
About how long have seizures been happening?
*
<1 year
1 to 5 years
5 to 10 years
10+ years
How far would you travel for seizure treatment?
*
<15 minutes
15 to 30 minutes
30 minutes to 1 hour
More than 1 hour
Other
Would you like to request a 15-minute call to see if the care service we are developing is right for you? (You can also email us at info@epicentercare.com)
*
Yes
No
First Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: