2022-CAP-HCA Virginia-Campaign-Johnston Willis Focused Ultrasound-PI

Complete the quiz below to request more information.

Question 1 of 5

Have you been diagnosed with essential tremors or Parkinson Disease?*

Yes No

Question 2 of 5

How long have you had the diagnosis?*

Less than a year More than one year

Question 3 of 5

Who is your current treating physician for this condition?*

Question 4 of 5

Are you currently on any medications for this condition? If so, what?*

Propranolol (Inderal®) Primidone (Mysoline®) Clonazepam (Klonopin®) Diazepam (Valium®) Lorazepam (Ativan®) Alprazolam (Xanax®) Gabapentin (Neurontin®) Topiramate (Topamax®) I have not taken medication(s)

Other:

Question 5 of 5

How did you hear about our facility?*

Internet Friend Physician

Other:

Your Information

Name*

First Name

Last Name

Phone*

Email*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code