Welcome Epilepsy Foundation of Texas
2019 Transition Focus Group Signup
Please enter information below and you will be on your way to Better Health!
Enter SignUp Information
First Name
Last Name
Mobile Phone Number
E-Mail
Zip Code
Choose your option
Male
Female
Other
Sex
Choose your option
0-12
13-18
19-25
26-35
36-50
51-65
66+
Other
Age Group
Choose your option
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other
Ethnicity
Have you visited the Emergency Room in the last six months as a result of a Epilepsy related incident?
Submit