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Deep Brain Stimulation Information Request Form

UW Health neurosurgeons and psychiatrists in Madison, Wisconsin, offer deep brain stimulation (DBS) for a variety of neurological conditions, including dystonia, essential tremor and Parkinson's disease.
 
Request for More Information
 
If you are interested in learning more about deep brain stimulation, or would like to refer a patient for consideration, please complete and submit the form below. A representative from our program will contact you.

Please use this form for general inquires only. Do not submit medical concerns and personal health information via this form. You will have the opportunity to review and discuss medical information when you are contacted.
 
Please do not submit urgent questions about your medical care through this website. If you are experiencing a life- or limb-threatening emergency, call 911. If your need is urgent, call your clinic for assistance.
 
Please complete all the form fields below. Thank you.
 

First Name
 
Last Name
 
E-mail Address
 
Phone Number (include area code)
Home  Cell
 
Mailing Address
 
 
Contact Preference
 
I would prefer to be contacted by:
 
Phone
E-mail
 
What type of information are you interested in?
 
I am a patient/family member who would like to discuss DBS.
I am a physician who would like to discuss referring a patient.
 
For which condition are you interested in receiving information?
 
Dystonia
Deep Brain Stimulation using iMRI
Essential Tremor
Parkinson's disease