Focused Ultrasound Evaluation Request | RUSH

First

Last

Suffix

Date of Birth

Cell Phone

Alternate Phone

Email Address

MRI-Guided Focused Ultrasound

Do you have a diagnosis of essential or parkinsonian tremor?

Yes

No

Have you previously taken medication for tremor?

Yes

No

Do you have any metal in your body that makes you ineligible for an MRI?

Yes

No

What is your primary insurance?

Medicare

Medicaid

Blue Cross Blue Shield (BCBS)

Other

Any additional information?