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#FixIt4Free: Tell us how epilepsy affects your teeth

Have you damaged your teeth due to a seizure or seizures but cannot afford the repairs? Have dental injuries left you too scared to smile?

Seizures can cause repeated injuries to teeth. And, in many cases, people with epilepsy have to bear the cost of multiple repairs. Or go without treatment

Our #FixIt4Free campaign is calling on the Government to to introduce a medical exemption for people with epilepsy who damage their teeth due to a seizure so they don’t face the burden of exorbitant dental fees and can have their teeth repaired free of charge.

If you have damaged or broken your teeth as a result of a seizure and are happy to share your story with us and to feature in the media, please get in touch.

IMPORTANT: On receipt of your completed form, we will keep your details on file and will be in touch if we are able to use your story. Please be assured that we would never pass on your details to the media without contacting you first. Any questions of concerns please feel free to contact the press office on 01494 601417.

PLEASE COMPLETE THIS FORM ONLY IF YOU ARE HAPPY TO SHARE YOUR STORY AND BE INTERVIEWED BY THE MEDIA.

PERSONAL DETAILS (OR THOSE OF THE PERSON YOU CARE FOR):

Male

Female

Other

Title

Date of birth

Please tell us your/their preferred method of contact:

Mobile

Direct message via:

Facebook

Instagram

About your/their epilepsy

Are you/they still having seizures?

Yes

Are you/they taking anti-epileptic medication?

Yes

If your/their epilepsy is not fully controlled, what type of seizures do you/they have?

tonic clonic (grand mal)

absence (petit mal)

simple partial

complex partial

other

If other, please specify below

How frequently do you experience seizures?

Multiple times a day

At least once a day

At least once a week

A few times a month

Every few months

On a rare basis

I can't remember the last time

Dental care

Have you/they experienced the following problems as a direct result of a seizure? Please tick all that apply.

Yes

Broken or chipped teeth

Cuts on tongue, lips or inner cheek

Tooth pain or agony

Jaw ache

Problems with gums

Other

If other, please write below

How frequently do you/they damage teeth as a result of seizures?

Very frequently

Frequently

Sometimes

Rarely

Never

When visiting the dentist have you/they experienced dental care costs that you cannot afford?

Yes

If yes, what options have you/they been offered or have you/they borrowed money, taken on an extra job to afford the fees?

How much has your/their dental treatment cost in the last five years?

If you have been unable to have your teeth repaired due to the cost, please tell us how this has made you feel and how it has impacted your life

When visiting the dentist have you/they experienced either of the following:

• Long waiting lists before getting treatment - how long have you/they typically had to wait to see your dentist in the last five years?

• Lack of awareness of epilepsy from dental professionals - please share any specific concerns you/they may have.

Have you/they received dental treatment at any of the following?

High street/general dentist

Emergency dentist

Hospital

Have you/they been able to claim exemption from dental costs as part of the NHS low income scheme?

Yes

Is there any other information you would like to tell us?

For example, your medical history (age at which epilepsy was diagnosed, treatment, etc)

Please confirm that you/they are happy to be interviewed by the media and for your story to be shared on our website and via social media.

Yes

Please confirm that you are happy to use your real name.

Yes

Please tick here if you would like to receive further details of our work

Yes

Keeping in touch

At Epilepsy Society we aim to keep you informed about the positive impact of your support on those affected by epilepsy. If you are happy to hear about our work, new fundraising and volunteering opportunities, donating and events, please select the preferred method of communication below:

Contact me by email or phone

Phone

You can change your preferences at any time by contacting us at donor.support@epilepsysociety.org.uk or by calling us on 0300 102 0026. For more information, please read our privacy policy.

About your/their epilepsy

Dental care

When visiting the dentist have you/they experienced either of the following:

Is there any other information you would like to tell us?

Keeping in touch

Thank you for sharing your experiences with us.