Keto Care

a referral from the treating neurologist is required and must be submitted with this application

referral form
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Keto Care Full Support Application

to help us determine eligibility and match to most appropriate dietitian

Name

What is your connection to Glut1 Deficiency?(Required)

Address(Required)

What is your preferred language?(Required)

How was the Glut1 Deficiency diagnosis confirmed?(Required)
check all that apply

Are you currently following any dietary restrictions?

Max. file size: 1,000 MB.

Agreements for participation(Required)

next steps

  • your application will be reviewed by the Glut1 Deficiency Foundation
  • you'll be notified of the decision within a week of application submission
  • if approved for participation in the Keto Care Project, a referral will be made to one of the participating dietitians
  • you'll be introduced to the dietitian by email to further coordinate care