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Name: ________________________________ Date: _________________________________
Phone Number: ________________________ FAX Number: ___________________________
E-Mail (this won't be posted on the www.cmdg.org site): ____________________________
City:________________________
Clinic Name(s): 1)_____________________________________________
2) _____________________________________________
Main Office Address:
______________________________________________________________________________________
University Affiliation: YES NO University Name: _____________________________________
Private Clinic: YES NO Name: _____________________________________________
______________________________________________________________________________________
Clinic Resources:
Nurses: Names: 1) ______________________________ 2)______________________________
3) ______________________________ 4)______________________________
Neurosurgeon: Names: 1) ______________________________ 2) _____________________________
Neuropsychologist Names: 1) ______________________________ 2) ______________________________
Neurophysiologist Names: 1) ______________________________ 2) ______________________________
Physiotherapy: Names: 1) ______________________________ 2) ______________________________
Social Worker: Names: 1) ______________________________ 2)______________________________
Occupational Therapy Names: 1) ______________________________ 2)______________________________
Other:_______________ Names: 1) ______________________________ 2)______________________________
_______________ Names: 1) ______________________________ 2) ______________________________
_______________ Names: 1) ______________________________ 2) ______________________________
Services Offered:
Movement Disorder Clinic dedicated to patient Care: YES NO
Areas of interest:
Parkinsons Huntingtons Tourettes Dystonia Tremor Myoclonus
Restless leg syndrome Other:________________________________________________
Basic Science Research: YES NO
If "YES" what type? : ___________________________________________________________________________
Movement Disorder Fellowship Offered ? : YES NO
Ongoing Clinical Studies:
(List if you want this info. put on the web site) YES NO
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
Functional Neurosurgery Offered? YES NO
Are you interested on being involved as a lecturer in any CME programs set up though the CMDG?
YES NO What Topics?: __________________________________________________________________________________________________
__________________________________________________________________________________________________
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