Name

First Name

Last Name

Email

Your website

http://

Name of study

Location of study

Hospital/university, country

Type of epilepsy

What type of epilepsy is focused on?

Study description

What's the purpose of the study?

Type of people required

Number of people required

Participant payment type

$

Date involvement commences

MM

DD

YYYY

Date involvement concludes

MM

DD

YYYY

Any more information

By submitting this form you grant us permission to contact you regarding the epilepsies.