You must have JavaScript enabled to use this form. If you have an essential tremor or parkinson's disease and would like to be evaluated for focused ultrasound treatment, please fill out the form below and click on the button labeled "Submit." If you'd prefer, you may also download and print this form and fax it to our patient coordinator at 801-581-4385. Patient Information Name (First, Last): * Date of Birth: * Date of Birth:: Year * Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Date of Birth:: Month * MonthJanFebMarAprMayJunJulAugSepOctNovDec Date of Birth:: Day * Day12345678910111213141516171819202122232425262728293031 basic address Address: * City: * State: * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code: * Phone Number: * Email: How Did You Learn About This Treatment?: Insurance Information Primary Insurance Name: * Primary Insurance Id Number: * Secondary Insurance Name (If Applicable): Secondary Insurance ID Number: Health Questions Have You Been Formally Diagnosed With An Essential Tremor By A Healthcare Professional?: Yes No How Many Years Have You Had Your Essential Tremor Symptoms?: * Please Check All The Anti-Tremor Medications You Have Tried Or Are Currently Taking For Your Tremors: Propranolol Primidone Gabapentin Topiramate Lorazepam Diazepam Clonazepam Mirtazapine Botox carbidopa-Levodopa (Sinemet, Rytary) Other If You Checked Off Other, Please List The Name Of The Anti-Tremor Medication: Do You Have Any Metal Implants Or Medical Devices That Would Prevent You From Having An Mri? (Please Check All That Apply.): Pacemaker ICD Spine stimulator Deep brain stimulator Pins Rods Shunts Clips Other I do not have a medical implant or metal device What Tasks Are You Having Difficulty Completing Due To Your Tremor?: Leave this field blank
