Epilepsy Review

Page {{ paginatorProps.current }} of {{ paginatorProps.total }} ({{ paginatorProps.percentage }}% completed)

All questions marked with a * are mandatory

Personal Details
Please double check you've entered the correct email address
May be used to identify you
Epilepsy Review
How long has it been since your last epileptic fit?: *
Are you currently on treatment for epilepsy?: *
How often do you have an epileptic fit?: *
Are you a woman aged between 18 and 55?: *
Would you like some information regarding contraception, conception and pregnancy and how this is affected by your epilepsy medication?: *

Please make an appointment with a clinician to discuss this further.


Privacy Consent


There appears to be a problem loading the form, please refresh the page.
If the error persists please contact us.