Contact Information
This form is a contact form for those currently diagnosed with Parkinson's Disease. This form will be stored in a registry of PD patients to be used for contact of new and upcoming studies with PragmaClin Research.
Have you been diagnosed with Parkinson's Disease? *
Have you been diagnosed with any other comorbidities? i.e., stroke, diabetes, etc.
Name *
Date of Birth
MM
/
DD
/
YYYY
Email *
Street Address *
Province & Postal Code *
Phone number *
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