Work Address *

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Personal or Office Phone

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Phone for appointments:

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Fax

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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