Doctor's Update 2 - Patient Research Volunteer Form: Person with PD

PD Research Introduction | Dr. Gosal's Article | Volunteer Information/Instructions | Control Volunteer Form

Please note: You will only be contacted for the purposes of this research. Your name will not be added to any database other than this one, and your contact will either be Dr. Gosal or another member of Dr. Lynch's team.

"YES, I'D LIKE TO PARTICIPATE IN YOUR RESEARCH!
This form - the GREEN FORM - is for the person with PD to complete

IF YOU ARE VOLUNTEERING A BLOOD SAMPLE FOR THE PD GROUP, PLEASE FILL IN YOUR DETAILS ON THIS PAGE.
Click HERE for the YELLOW form if you are a friend or relative or spouse of the person with PD.
Any information you supply will be treated as confidential, and will be used only to verify your age when diagnosed, and to contact you as and when necessary.
I am a person with PD, and I would like to help by providing a blood sample. I understand that the results of the analysis of my blood sample can not be divulged to me.

Your name

Male or female
Your age

Your age when diagnosed

Type your address here:

Phone number (daytime)

Your email address

Country in which you normally live?

Have you any relatives with Parkinson's disease? Yes/No
If Yes, please list:

If there is anything else you feel might be relevant to add , please do so in this text box: Additional information:

-Click on "SUBMIT" to send this form to Dr. Gosal. Someone from the team will then contact you to arrange to obtain a blood sample. Our thanks go to you.