Join HealthCare Professionals Form

First Name:*

Last Name:*

Practice Name:*

Address:*

City:*

Country:*

Zip or Postal Code:*

Fax: (xxx)xxx-xxxx

Work Phone:*(xxx)xxx-xxxx

E-Mail:*

Web Site Address:

Notes
(One or two sentences only):

Forms of Dystonia Treated:
Blepharospasm
Tardive Dyskinesias/Dystonia
Cervical Dystonia (Spasmodic Torticollis)
Dopa-Responsive
Early-Onset Generalized
Embouchure Dystonia
Myoclonic Dystonia
Oromandibular
Paroxysmal Dystonia
Rapid-Onset Dystonia-Parkinsonism
Secondary Dystonia
Spasmodic Dysphonia
Writers Cramp
X-Linked Dystonia-Parkinsonism

Administer Botulinum Toxin Injections for:
Blepharospasm
Lingual (Tongue) Dystonia
Oromandibular (Jaw) Dystonia
Cervical Dystonia (Spasmodic Torticollis)
Dopa-Responsive
Early-Onset Generalized
Embouchure Dystonia
Myoclonic Dystonia
Oromandibular (Jaw) Dystonia
Paroxysmal Dystonia
Rapid-Onset Dystonia-Parkinsonism
Secondary Dystonia
Spasmodic Dysphonia
Writers Cramp
X-Linked Dystonia-Parkinsonism

Other Specialties:
Acupuncturist
Family Practitioner
Genetic Counselor
Neurologist
Neurosurgeon
Nurse Practitioner
Orofacial Pain Specialist
Ophthalmologist
Otolaryngologist (ENT)
Pediatric Neurologist
Psychologist
Physical/Occupational Therapist
Speech-Language Pathologist-Therapist
Physiatrist
Movement Disorders Specialist

Other Procedures:
Counseling Services
Botulinum toxin type A (Botox®, Dysport®)
Botulinum toxin type B (Myobloc®, Neurobloc®)
Alternative/Complementary Therapies
Intrathecal baclofen
Deep Brain Stimulation
Genetic Counseling
Swallowing Therapy
Genetic Testing
ITX Injections
Myectomy
Pallidotomy
Phenol Injections
Physical/Occupational Therapy
Selective Denervation Surgery
Selective Laryngeal Adductor Denervation
Speech/Voice Therapy
Thalamotomy

Do you treat children?
No Yes

Would you like to receive our Physician Literature Kit, which contains educational literature on Dystonia for you to distribute to your patients?
No Yes