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Contact Information and Staying in Touch
The contact information you provide the Big Easy Parkinson's Support Group will be used to send you emails and/or texts about our monthly meetings and resources.
OK
1.
First Name
2.
Last Name
3.
Person with Parkinson's Disease Address
Address
City
State
Zipcode
Email Address
Phone Number
4.
Birthday
5.
Physician (Parkinson's)
6.
Caregiver Name
7.
Caregiver Phone Number
8.
Caregiver Email Address
9.
Would you like to hear from us through email?
Yes
No
If yes, which email address (person with Parkinson's, caregiver or both)?
10.
Would you like to hear from us through text? (Reminders for meetings day/time)
Yes
No
If yes, which phone number (person with Parkinson's, caregiver or both)?
11.
Do you have any suggestions for future speakers at the meetings?
12.
Are there any resources you would like to share?
13.
Do you have any pressing needs that we could possibly help with?
14.
Other Comments
Current Progress,
0 of 14 answered
