Registration

Taking care for your cure

To register and take your place in the line of our patients for the CCSVI treatment at Euromedic Clinic, please fill in the questionnaire below.

After registration process we will inform you about the details of your CCSVI/MS treatment.

	1. Name*
	2. Last Name*
	3. E-mail address*
	4. Telephone number*
	5. Country*
	6. City*
	7 Age*
	7.1 Date of birth (rrrr-mm-dd)*
	8. Sex*	Female Male
	9. Height*	Cm Inch
	9.1 Height*
	10. Weight*	Kg Pounds
	10.1 Weight*
	11. Is patient using a wheelchair ?*	Yes No
	12. Is the patient able to stand up and take a few steps ?*	Yes No
	Additional remarks:
	13. Does this patient have problems: moving, bending down?*
	14. Does this patient have problems: speaking and swallowing?*
	15. Have the patient had MRI scan of jugular veins and azygos vein done ?*	Yes No
	16. Have the patient had Doppler ultrasound exam of jugular veins done ?*	Yes No
	17. Will the patient need wheelchair adjusted accommodation (handlebars in the bathroom) ?*	Yes No