Survey - Request for Information for Healthcare Professionals

CurePSP is pleased to offer you a comprehensive information package on PSP, CBD or MSA. We ask for a suggested donation of $10 to allow us to continue printing these materials for patients and families in the future. Donations can be made at www.psp.org/donate. Please answer all questions below so that we can respond to your inquiry as accurately as possible. Thank you for reaching out to us.

Your details:


*	Title:
*	First Name: Required
*	Last Name: Required
*	Email: Required
*	Street 1: Required
	Street 2:
*	City: Required
*	State / Province: Required
*	ZIP / Postal Code: Required
*	Country: Required
*	Phone Number: Required
	Yes, I would like to receive e-mail from CurePSP
	Yes, I would like to receive postal mail from CurePSP

Question - Not Required - Name of clinic you are requesting these materials for:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Are you currently treating a patient(s) with PSP, CBD, or MSA?

*

Question - Required - Is there a support group currently affiliated with your clinic?

	Yes
	No
	I don't know

*

Question - Required - For which disease(s) would you like educational material?

	PSP
	CBD
	MSA

*

Question - Required - How many copies of the materials would you like? 5
10
20

To speak with someone directly regarding these materials, please call our office at 347-294-2871

Request for Information for Healthcare Professionals

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