Epilepsy Review Form

Please only complete the form below if the surgery have asked you to.

Please select the practice location most relevant to this Online Form submission:

Your Details

Title

First Name

Surname

Date of BirthDD/MM/YYYY

Address

Post Code

Telephone Number

Review Questions

How long ago was your last epileptic fit?

Are you currently being treated for epilepsy?

How often do you have an epileptic fit?

Are you a woman aged between 18 and 55?

If yes, would you like some information regarding contraception, conception and pregnancy and how this is affected by your epilepsy medication?

I confirm that to the best of my knowledge the information provided in this form is correct

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All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Plumstead (Main Branch) • Plumstead (Main Branch), 44 Conway Road, Plumstead, London, SE18 1AH .

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

Local Services

Key Information

BBC Health News

Epilepsy Review Form

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