Name:*
E-mail:
Phone:*
-
Address:*
Message:*
Date of Birth:*
When were you diagnosed with Parkinson's disease?:*
What current medications with daily dosing value of each that you are taking for your Parkinson's symptoms?: *
Are you currently prescribed a daily dose of medications containing 1200mg of L-Dopa or more?: *
Are you currently receiving DBS (deep brain stimulation) treatment?:*
Is the patient wheelchair bound, institutionalized, or immobile?:*
Does the patient have the ability to have video conferences with a computer, tablet, or cell phone with high-speed internet?:*
Verification:

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