CACNA1A Foundation Contact Registry

This survey is HIPAA compliant.

First Name *

Last Name *

Address

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Email Address *

Phone Number

CACNA1A/Cav2.1 Facebook Group or other group on social media

Searching the Web (e.g. Google)

Genetic testing company

Referral from friend or family

Neurologist or other clinician

other

Other (please specify)

Other (please specify)