Request a Consultation for Focused Ultrasound

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.

Name (First, Last): ^*

Date of Birth: ^*

Address: ^*

City: ^*

State: ^*

ZIP Code: ^*

Phone Number: ^*

Email:

How Did You Learn About This Treatment?:

Primary Insurance Name: ^*

Primary Insurance Id Number: ^*

Secondary Insurance Name (If Applicable):

Secondary Insurance ID Number:

Have You Been Formally Diagnosed With An Essential Tremor By A �ǿմ�ýcare Professional?:

Yes

How Many Years Have You Had Your Essential Tremor Symptoms?: ^*

If You Checked Off Other, Please List The Name Of The Anti-Tremor Medication:

What Tasks Are You Having Difficulty Completing Due To Your Tremor?: