Report A Seizure Form

This is a tool to help monitor and record seizures. Emergency cases must always go to the nearest hospital or clinic.
Do not fill this form out if you're a solicitor.
Pet Parent's Name*
First Last
Contact Number*
Email Address*
Pet's Name*
Who is your pet's neurologist?*
Date(s) of Seizure(s)*
Please enter date of all seizure events.
Time(s) of Seizure(s)*
Duration of Seizure(s)*
Current Medications*
Recent change in medications (any missed doses?)*
Any additional medications administered? (Valium, etc)*
Date of last seizure (prior to this event)
Description of event (# of seizures, duration, frequency)*
- I would like to be contacted about this seizure
Preferred Contact Method
- Phone
- Email
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

Questions?