Public Relations Patient Story Request Form

Please fill out the following form to request a patient story in your area. We know that demand for local coverage is high, and we will pitch as many appropriate stories as we can. The more information you are able to provide and the better the story/results, the more likely we are to have the physician/patient story featured.

We will review every request. If we are able to move forward, we will contact you directly.

Public Relations Patient Story Request Form

Your Name

Phone Number

Case Manager

Physician Information

Physician Name

Phone Number

Address

Email Address

Confirm that you have discussed PR opportunities with the physician. *

Yes

Hospital Information

Hospital Name

Address

PR/communications contact at hospital

Phone Number

Email Address

Patient Information

First Name

Last Name

Gender

Female

Male

Guardian (first name only) if under 18 or requiring a caregiver

State + 1st 3 digits of zip code

Year of birth

Was this patient on label when implanted?

Yes

Occupation or Grade

Model number

Seizure type, if known

Local Epilepsy Foundation Contact (if available)

Patient Story *

Public Relations Patient Story Request Form

Public Relations Patient Story Request Form

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