Free NPH Information Kit
Please complete this form to receive your free NPH information package. Completing the entire form will better help us provide you with information specific to your needs.

* required       *This is for: Myself Someone else Healthcare Provider *Title   Mr. Mrs. Ms.   *First Name     *Last Name     *Address     Suite/Apt #     *Phone ex: 8668772471 *City     Best time to reach   8AM to 12 Noon 12 to 5PM 5 to 9PM *State   -- Choose a State -- Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   *Email   *Zip     Birth year   Four Digit Year   This section is important and will help us provide you with the most relevant information to better serve your request. Do you lose your balance unexpectedly or have difficulty walking? Yes No Don't know Do you have difficulty lifting your feet when you walk, causing you to sway from side to side and does it feel like your feet are stuck to the floor? Yes No Don't know Are you finding that you have difficulty maintaining attention or remembering things? Yes No Don't know Have you experienced sudden urgency in urinating or have had urinary accidents? Yes No Don't know Have you been diagnosed with NPH (Normal Pressure Hydrocephalus)? Yes No Don't know Have you been previously diagnosed with Alzheimer’s disease or Parkinson’s disease? Alzheimer's Parkinson's Both What is the specialty of the physician who diagnosed you with Alzheimer's or Parkinson's? Neurosurgeon Neurologist General Practitioner Patient Care Pratitioner Psychiatrist Other

* I understand that my information will be used by Codman and its affiliates to send a free NPH information kit. Codman may also contact me about other products and programs that may interest me. Codman will not share my information with anyone except as required by law or stated in our privacy policy. I would to like to immediately download the NPH information package instead of having it mailed to the address above.