人妻中出视频

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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

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Insurance Information

人妻中出视频 Questions

Have You Been Formally Diagnosed With An Essential Tremor By A 人妻中出视频care Professional?:
Please Check All The Anti-Tremor Medications You Have Tried Or Are Currently Taking For Your Tremors:
Do You Have Any Metal Implants Or Medical Devices That Would Prevent You From Having An Mri? (Please Check All That Apply.):