JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Let's Talk About Function Seizures - sign-up
Sign in to Google
to save your progress.
Learn more
* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Email address
*
Your answer
Phone number
*
Your answer
Resident of Ontario?
Yes
No
Clear selection
City of Residence?
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
How did you hear about Epilepsy Toronto?
*
My neurologist
My family doctor
Another community epilepsy agency
Website / Google search
Social media
Other:
Please click the option that best applies to you:
*
I have been diagnosed with functional seizures / PNES
I am the loved one of a person diagnosed with functional seizures
I work with people who have functional seizures
My doctor told me that I **may** have functional seizures, but the diagnosis is not yet confirmed
My loved one's doctor told them that they may have functional seizures, the diagnosis is not yet confirmed
Other:
I want to attend ‘Let’s Talk About Functional Seizure’ on the following date/time:
*
Friday May 3, 2024, 12pm-1:30pm
Friday, July 12, 2024, 12pm-1:30pm
Friday, September 6, 2024,12pm-1:30pm
Friday, November 1, 2024, 12pm-1:30pm
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Epilepsy Toronto.
Report Abuse
Forms
