ECHO Epilepsy: Patient Case Support Form

Do you have a patient case related to epilepsy or seizures that you would like to discuss at an upcoming ECHO Session?

We want to hear from you!

Our virtual ECHO sessions offer healthcare providers with access to advice, support and written recommendations from specialists and multi-disciplinary providers, without the wait times.

Present your de-identified case for a safe and supportive discussion led by epilepsy experts in collaboration with the community.

**Do not share any patient identifying information during the case presentation

Question Title

* 1. *Case Specialty

Children and Youth (0 - 18 years old)

Adult (18+ years old)

Genetics

Question Title

* 2. *Health Provider Information

Full Name

Clinical Site

Profession

City/Town

Email Address

Question Title

* 3. *Primary Concerns (3-4 Questions for ECHO)

We look forward to connecting and discussing how best to manage your patient. We will follow up with you shortly with additional information.

If you have any questions/concerns please feel free to reach out to Sania Siddiqui, ECHO Epilepsy Program Coordinator at sania.siddiqui@sickkids.ca