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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

basic address

Insurance Information

Health Questions

Have You Been Formally Diagnosed With An Essential Tremor By A Healthcare 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.):