RNS Ambassador Information
Year you were born:
Month/year you RECEIVED the RNS system:
Name of doctor treating you with the RNS System:
Epilepsy Center where you had the procedure:
epilepsy center where you are currently being treated:
Which programs are you interested in participating? (Check all that apply)
Connect 1:1 Connect Local Connect Social
How do you want to connect with interested patients?
Leave this empty:
Signed by NeuroPace Inc.
Signed On: September 22, 2016
If you have questions about the contents of this document, you can email the document owner.
Document Name: RNS Ambassador Information
Agree & Sign