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Physician's First Name (required)

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Degree (required)

Institution/Practice Name (required)

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ZIP Code (required)

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Public Email

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How many dystonia patients do you see in a month? (required)

What forms of dystonia do you treat?

Acquired (Secondary) DystoniaBlepharospasmCervical Dystonia/Spasmodic TorticollisDopa-Responsive DystoniaFocal Limb DystoniaFunctional/Psychogenic DystoniaGeneralized -Childhood/Adolescent OnsetGeneralized - Adult OnsetMyoclonus-DystoniaOromandibular/Embouchure DystoniaParoxysmal Dystonia/DyskinesiasPrimary Torsion DystoniaRapid-Onset Dystonia-ParkinsonismSpasmodic Dysphonia/Laryngeal DystoniaWriters Cramp/Hand DystoniaTardive Dyskinesias/DystoniaX-Linked Dystonia-Parkinsonism

Do you treat children? (required)
YesNo

Do you offer telemedicine appointments? (required)
YesNo

Do you wish to join the DMRF mailing list? (required)
YesNo

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