Form Page

First Name*

Last Name*

Phone*

e.g. 555-555-5555

Email*

Were you or a loved one exposed to Paraquat?*

Yes

Were you or a loved one diagnosed with Parkinson's Disease?*

Yes

Year of Diagnosis

Please feel free to include additional details about your exposure to paraquat:

When would be a good time to call you?

Central Time

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I Consent