Clinical Trial & Purchase Interest Form


Please fill in the form, if you are interested in taking part in future clinical trials,
and/or if you live in the USA and are interested in purchasing a device,
once ScyFIX has received FDA approval for selling and distribution in the USA. 
Your information will of course be treated confidentially. Your information will contribute 
to the development of our therapy. We will contact You as soon as we have more information 
on future trials or marketing approvals. Thank You!

Please fill in the following information:

Name
Last name
Initial
Interested in trial?
Interested in purchase?
Address
Address (cont.)
ZIP code
City
Country
Telephone, work
Telephone, home
Age
E-mail
Ocular disease

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