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.

**please allow 10-14 business days for your order to arrive

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 - Which educational materials would you like to receive?

	PSP Some Answers, Medical Alert Card, Disease Summaries
	CBD Some Answers, Medical Alert Cards, Disease Summaries
	MSA Some Answers, Medical Alert Cards, Disease Summaries
	CTE Some Answers
	CurePSP General Information Pamphlet
	PSP/CBD/MSA Brief Descriptions
	Allied Healthcare Brochure
	Brain Tissue Donation Brochure

*

Question - Required - How many copies of the materials would you like? 5
10
25

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

Request for Information for Healthcare Professionals

Join Our Mailing List