Name of participant: *

First Name

Last Name

Participant Date of Birth *

MM

DD

YYYY

As part of this study, we will be collecting data using the vCreate Health platform. Do you/your child already have an account on your local vCreate Neuro service? *

Yes

No

If no, are you happy for your clinical team to invite you to the vCreate Health platform?

(you will be provided with further information about vCreate Health and how the platform is used in Neurology services)

Yes

No

Please select from the below: *

I am happy to read the study information sheets and complete the study consent forms on the vCreate platform

I want to receive study information sheets by post and complete the informed consent form with my local clinician

Phone

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you happy to receive study information in English? *

Yes

No

Will the person you are submitting this form for be able to fully understand the information about this study and give consent for themselves? *

Yes

No

Would you like to be kept up to date with the EPI-SCOT study via newsletter correspondence? *

Yes

No