Sign-Up for Zhittya’s Parkinson’s Disease Trials and Studies Sign-up for our Parkinson’s Disease Clinical Trials and Medical Research Studies! Name * First Name Last Name Email * Phone * Country (###) ### #### City * State/Province (US/Canada) * Not in the US/Canada Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon ZIP Code * Country of Residence * United States of America Canada United Kingdom Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling Islands) Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire (Ivory Coast) Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France Metropolitan France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea (North) Korea (South) Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda St. Georgia and the Sandwich Islands St. Kitts and Nevis St. Lucia St. Vincent and The Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Minor Outlying Islands Uganda Ukraine United Arab Emirates Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands (British) Virgin Islands (US) Wallis and Futuna Islands Western Sahara Yemen Zambia Zimbabwe Age * Gender Assigned at Birth * Male Female Have you been diagnosed with Parkinson's Disease by a Medical Professional? * Yes No Do you have DBS? * Yes No I had it, but it has been removed If you know, what stage of Parkinson's Disease do you have? * Stage I Stage II Stage III Stage IV Stage V What are your symptoms? * Are you willing and able to travel to a trial or research site that may be outside of your home nation? * Yes No Can you commit to being at the treatment location for one week? * Yes No Do you have a current passport? * Yes No Where did you hear about us? * Google Facebook/Instagram YouTube Referral Other
