Seizure Alert Programme Registration

Email address (required)

First Name (required)

Last Name (required)

Address (required)

Town/City (required)

Post Code (required)

As a small charity it is vital to us that we are able to keep you up to date on our work and activities by sending you occasional emails about our work, events, appeals and fundraising. Please tick to allow us to do this

Yes I am happy to receive this

Phone number (required)

Do you have a confirmed diagnosis of epilepsy (required)

Yes

Do you have a vagal nerve stimulator implanted (required)

NoYes - and it is turned onYes - but it is turned off

Do you have at least 10 major seizures per month (required)

Yes

Have you had an changes in medication that would affect your epilepsy within the last 6 months or are you expecting a change in medication in the near future? (required)

No

Do you have 6 months worth of seizure diaries? (Diaries will be requested during your information day interview)

Yes

On average how many seizures do you experience each month?

What type or types of seizures do you experience?

Do you currently have a pet dog? (required)

No

If you are successfully allocated a place at an information day, would you be able to bring someone with you? (required)

Yes

Are you aged 16 or over? (required)

Yes

How would you describe your ethnicity? (optional)

Prefered method of contact

Email SMS Text messagePhone What’s App Post