Tri-State Parkinson's Wellness Community

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Request Information

We would be glad to send you a free packet of information. Fill out the form below or call us at 513-948-1100 or 1-877-489-1110. We also offer more literature that you can request by mail. Click here for a listing of booklets you can request.

The asterisk (*) indicates a required field.
First Name:*	Last Name:*

Street Address:*	Age:

Street Address:(2)	How long have you been diagnosed?

City:*	State:*

ZIP Code:*	Email:

Home Phone:	Work Phone:

I am ...
a person with Parkinson's. a family member. a friend.
a health care worker. other. (If other, specify below.)

other:

I would like a referral to a... neurologist support group.

I'd like to receive a PD information packet.
I'd like to receive a donation envelope.
I'd like to receive an emergency room packet.
(packet with contraindicated drug information)
I'd like a packet on getting involved in the chapter.
I'd like to receive the chapter's newsletter.
I'd like to be informed about upcoming events.
I'd like to be contacted by telephone.

Particular symptoms and problems:

Additional comments:

As mentioned above, we also offer a further, extended selection of pamphlets and booklets (PDF) that you can order by mail. All literature is free.

Tri-State Parkinson's Wellness Chapter
4 Triangle Park Drive
Suite 404
Cincinnati, OH 45246-3401

Telephone: 513-948-1100
or toll-free 877-489-1110
Email: info@parkinsonswellness.org