Work Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Personal or Office Phone

This will not be published.

Country

(###)

###

####

Phone for appointments:

Country

(###)

###

####

Fax

Country

(###)

###

####

Have you in the past and/or are you currently treating patients with the following: (Check all that apply)

KCNT1

SCN2A

SCN8A

DRAVET

Intractable epilepsy (unspecified forms)

I am the above referenced person or have been authorized by that person to complete this form on their behalf and I allow the KCNT1 Epilepsy Foundation to use this information on its website directory. *

Yes

No

Do you currently work with underserved or underrepresented communities?

Yes

No

I would like to receive updates about research, studies and trials from the KCNT1 Epilepsy Foundation.

Yes

No

I would be interested in serving as a clinical trial site for a new treatment at my institution.

Small molecule

ASO

Gene therapy

Off-label option

Other procedure

I would like to be invited to a private communication channel on Slack.

Yes

No

Maybe. Send me more info

I have read and understand the Privacy Policy. *

I consent