PANDA - CLINICAL TRIALS

CLINICAL TRIALS

PATIENT QUESTIONNAIRE
Thank you for your interest in our Clinical Research Trials!

Please provide the participant's name, date of birth and the condition and/or study that you are interested in.

If we have a clinical trial that may be appropriate for you, we may call you for more information and to confirm further details.
Name:*

FirstLast
Date of Birth:*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Please choose one or more conditions of interest:*

MigraineEpilepsyCluster HeadachesCerebral PalsyAutismOther Neurological Conditions (Ages 2 - adult)
If you would like to narrow your participation to a more specific Epileptic diagnosis, please provide more information below.
Please specify the type of Neurological Condition that you are interested in:
Should be Empty: