Webinar: Accessing Epilepsy Healthcare Right For You (Request Recording) First Name Last Name Email Phone Zip Code Organization/Employer Industry TypePlease select... Affiliate Business Clinic College/Higher Ed Corporate County Social Services Education: Day Care/Head Start Education: District School/Area School Education: Elementary School Education: High School Education: Middle/Jr High School Fire/Police/Emergency Personnel Foundation Government Group Home Home Health Care/Adult Day Service Hospital Media Mental Health Services Nonprofit Religious Organization Secondary Clinics Senior Serving Organization Service Club Vendor Youth Organization Other Please specify: How many individuals will be viewing this video? What is your relationship to epilepsy?I have epilepsy/seizuresMy child has epilepsy/seizuresMy parent has epilepsy/seizuresMy spouse or partner has epilepsy/seizuresAnother family member has epilepsy/seizuresI lost someone who had epilepsyA friend/co-worker has epilepsy/seizuresI work with people who have epilepsy/seizuresOther/prefer not to respond Is this your work email?Please select... Yes No Email listed above Work Email How did you hear about this webinar?Please select... EFMN E-Newsletter EFMN Events Newsletter EFMN Staff EFMN Website Employer Eventbrite Physician Social Media Staff Member Name Would you like a Certificate of Completion?YesNo reCAPTCHA helps prevent automated form spam. The submit button will be disabled until you complete the CAPTCHA. Contact Information