Add a Provider

If you are a healthcare professional that treats people with spasmodic dysphonia, you are welcomed to be added to our referral list by submitting your contact information below:

State:


First Name:


Last Name:


Practice Name:


Address:



City:


Country:


Zip or Postal Code:


Work Phone:(xxx)xxx-xxxx


Fax: (xxx)xxx-xxxx


E-Mail:
(Please note: E-mail addresses are not listed on the website, for internal use only)

Web Site Address:
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Notes
(One or two sentences only):


Administer Botulinum Toxin Injections for:
Spasmodic Dysphonia - Adductor
Spasmodic Dysphonia - Abductor
Other Forms of Dystonia


Forms of Dystonia Treated:
Spasmodic Dysphonia
Other Forms of Dystonia


Medical Specialty:
Movement Disorders Specialist
Neurologist
Otolaryngologist (ENT)
Speech-Language Pathologist-Therapist


Treatments:
Selective Laryngeal Adductor Denervation
Speech Therapy
Thyroplasty
Other:


Would you like to receive our Healthcare Literature Kit, which contains educational literature on Spasmodic Dysphonia for you to distribute to your patients?