PATIENT APPLICATION / NEXT GENERATION PDT

Should you wish your individual case for Next Generation PDT to be considered, please fill out the form below providing as much information as possible about your condition. Upon receiving your application we will send you a secure login to provide us with the required medical documents.

FIRST NAME *
LAST NAME *
PATIENT SEX *
 
CHOOSE PASSWORD *
RE-ENTER PASSWORD *
 
COUNTRY *
EMAIL ADDRESS *
PHONE NUMBER
 
CONDITION INFO *
NOTE: Please include as much information as possible about your condition.
ABLE TO TRAVEL Are you able to travel if necessary for treatment?