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Epilepsy Advocate
Strength in numbers™

Live Well with Epilepsy

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Sign Up for the Epilepsy Advocate Program

Join a community of people who are living well with epilepsy

Just fill in the form below to join the Epilepsy Advocate program. As a member, you’ll get information about living well with epilepsy, including:

  • Monthly emails with tips and support for people with epilepsy and their family, friends, and caregivers
  • FREE issues of EpilepsyAdvocate magazine, with informative and inspiring articles

We are committed to protecting your privacy. Please see the UCB, Inc. Privacy Policy for more information.


*Required

Why?
 
Epilepsy Advocate Spring 2012
Yes, I’d like to receive my FREE issue of EpilepsyAdvocate magazine by mail.
Why?

Help us help others with epilepsy

Understanding your treatment experience helps us provide helpful information to you and others whose lives are affected by epilepsy.

*Please select from the list below all the medications you or the person you care for is currently taking.

Carbatrol® (carbamazepine) Neurontin® (gabapentin)
Depakote® (divalproex sodium) Phenobarbital
Depakote® ER (divalproex sodium) Tegretol® (carbamazepine)
Dilantin® (phenytoin) Tegretol®-XR (carbamazepine)
Gabitril® (tiagabine HCl) Topamax® (topiramate)
Keppra® (levetiracetam) Trileptal® (oxcarbazepine)
Keppra XR® (levetiracetam) extended-release Vimpat® (lacosamide) C-V
* How long?
Lamictal® (lamotrigine) Zonegran® (zonisamide)
Lamictal® XR™ (lamotrigine) Other
Lyrica® (pregabalin) C-V None

Please answer a few brief questions to help us help you better

Please tell us a little more about your life with epilepsy and your treatment plan. This information helps us understand our subscribers better so we can provide the best support system—designed just for them. We respect your privacy; your answers will be used only to help us improve the program. Please read our privacy policy for more information.

1. Overall, how much of an impact does epilepsy and/or seizures have on personal life (ie, personal relationships, leisure, or home life)?

No Impact Moderate Impact Major Impact
2. I constantly worry that I will hurt myself or others while having a seizure.

Totally Disagree Neither Agree nor Disagree Totally Agree
3. I actively seek out information about new ways to cope with epilepsy.

Totally Disagree Neither Agree nor Disagree Totally Agree
4. How concerned are you, if at all, about the possibility of having a seizure in the next 12 months?

Not at All Somewhat Extremely
5. How likely, if at all, do you think it is that you will be restricted from driving in the future due to epilepsy or seizures?

Not at All Somewhat Extremely

By providing this information, I give UCB, Inc. permission to send me information about epilepsy medication and other similar products from UCB, Inc. and its business partners. I understand that UCB, Inc. or its business partners will not sell or transfer my name, address, email address, or any other information to any other party for their own marketing use. I can remove myself from the mailing list at any time by clicking "Unsubscribe" on the eNewsletters that I will receive.

Please review the privacy policy of UCB, Inc.

VIMPAT is a registered trademark used under license from Harris FRC Corporation. All other registered trademarks are the property of their respective owners.