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神経因性膀胱を治療できる世界で唯一の場所

Free Evaluation Application Form

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日
Gender
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How did you learn about the Xiao procedure or our hospital?
Single choice
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Your responses to the following questions will be reviewed by our physicians to determine your candidacy for Xiao procedure

What type of illness do you have?
Spina Bifida/Myelomeningocele
Spinal Cord Injury/Paraplegia
Neurogenic Bladder Caused by Radical Surgery
Neurogenic bladder caused by other factors

We value your privacy and confidentiality. Our free evaluation does not require you to provide any personal medical information. However, if you choose to share some relevant details (electronic documents) that could assist in the evaluation of your condition, you are welcome to do so voluntarily. Your trust and comfort are our top priorities. You can upload the additional electronic documents through the following methods.

Please upload any electronic documents you consider important about your condition. The file format is not limited, and the total number of files should not exceed 10.

Disclosure: We respect your privacy 100%, so the information that you provide will remain strictly confidential. Nevertheless, a copy of your message might be stored in our records as a database entry for archival purposes.

母国語で無料評価フォームを送信してください

母国語が英語でない場合は、右側のボタンをクリックして直接メールでお問い合わせください。必要と思われる情報をできるだけ多くご記入いただければ、それに基づいてお客様の状態を評価させていただきます。

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