Section 1: General Information

📌 Clinic / Research Center Name: _______________________________________

📌 Affiliated Institution (if applicable): ___________________________________

📌 Primary Contact Name: _____________________________________________

📌 Title/Position: ____________________________________________________

📌 Phone Number: __________________________________________________

📌 Email Address: ___________________________________________________

📌 Website: ________________________________________________________

📌 Clinic/Center Address: _____________________________________________

📌 City, State, ZIP: _________________________________________________

📌 Country: ________________________________________________________

Section 2: Facility & Research Capabilities

1. Facility Type: ☐ Private Clinic ☐ Hospital-based Research Unit ☐ University Research Center ☐ Independent Research Organization ☐ Other: ______________________
2. Areas of Expertise (Check all that apply): ☐ Neurology ☐ Functional Neurology ☐ Chiropractic Care ☐ Physical Therapy ☐ Occupational Therapy ☐ Sports Medicine ☐ Neuroscience Research ☐ Geriatrics ☐ Rehabilitation Medicine ☐ Balance & Vestibular Therapy ☐ Cognitive & Memory Disorders ☐ Other: ______________________
3. Available Equipment & Technologies (Check all that apply): ☐ Eye-tracking devices ☐ Motion analysis systems ☐ Balance assessment tools ☐ Vestibular testing (e.g., vHIT, caloric testing) ☐ Neurocognitive assessment tools ☐ Gait analysis systems ☐ MRI / fMRI / PET scan access ☐ EEG / EMG capabilities ☐ Other: ______________________
4. Current Patient Population: Approximate number of Parkinson’s patients seen annually: ________ Do you currently conduct Parkinson’s-related research? ☐ Yes ☐ No If yes, briefly describe ongoing projects:
5. Clinical & Research Team Please list the primary clinicians/researchers who will be involved in the study: Name Title/Role Area of Expertise Years of Experience

Section 3: Participation in NeuroAI Parkinson’s Study

1. How would you like to participate? (Check all that apply) ☐ Conduct patient assessments using NeuroAI technology ☐ Recruit and enroll patients for the study ☐ Collect and report patient data for research analysis ☐ Provide treatment and follow-up care for study participants ☐ Conduct independent research using NeuroAI tools ☐ Assist in developing new assessment protocols
2. Patient Recruitment & Retention Strategy How do you plan to recruit patients for the study? (Check all that apply) ☐ In-clinic referrals ☐ Online outreach ☐ Social media ☐ Physician referrals ☐ Parkinson’s support groups ☐ Other: _________ How many patients could you enroll per year? ________ Do you have experience managing multi-center research studies? ☐ Yes ☐ No
3. Data Collection & Compliance Are you familiar with Good Clinical Practice (GCP) guidelines? ☐ Yes ☐ No Do you have an Institutional Review Board (IRB) or Ethics Committee in place? ☐ Yes ☐ No How will you ensure patient confidentiality and data security?

Section 4: Technology & Support Needs

1. What type of support would you require from NeuroAI? (Check all that apply)

☐ Training on NeuroAI assessments and technology

☐ Assistance with regulatory compliance & IRB approvals

☐ Patient recruitment & marketing materials

☐ Data collection & analysis tools

☐ Funding or grants for research operations

☐ Ongoing technical support

1. Would you be interested in co-authoring research publications? ☐ Yes ☐ No
2. Additional Comments or Requests:

Section 5: Agreement & Signature

By submitting this application, I confirm that my clinic/research center is interested in becoming a NeuroAI Research Partner. I acknowledge that participation in this study will involve adhering to research protocols, collecting data ethically, and maintaining compliance with all regulatory requirements.

📌 Authorized Representative Name: _________________________

📌 Title/Role: _________________________

📌 Signature: _________________________

📌 Date: _________________________

Next Steps:

✔ Submit this completed form to [Your Email/Portal]

✔ Our team will review your application and schedule an introductory meeting

✔ Approved sites will receive onboarding materials and training sessions

Thank you for your interest in becoming a NeuroAI Research Partner!