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FlowOx™ 30 Day @Home Evaluation Program for pwMS
Register online your expression of interest
FlowOx (30-DAY) @ Home Evaluation Program for pwMS
Expression of Interest
Are you over 18+ years of age?
Yes
No
First name
*
Last name
*
Email Contact
*
Suburb or Postcode
*
Preferred Contact Number (Optional)
What MS symptoms are you mostly experiencing? (Optional)
Spasticity
Nighttime Spasms
Sleep Disruption
Lower-Limb Discomfort
Swelling
Other
MS Subtype (optional)
(RRMS) Relapsing-Remitting MS
(SPMS) Secondary Progressive MS
(PPMS) Primary Progressive MS
Other
Are you able to sit comfortably for 1 hour per day
*
Yes
No
Other
Are you currently supported by a neurologist, MS Nurse Specialist, Physio, OT or other clinician. (Optional)
Yes
No
Other
30 Day @ Home Evaluation Program Consent to Contact
*
I agree to be contacted by Heal-Med Solutions regarding FlowOx Home Evaluation Program
Other
Preferred Start Date (Optional)
Please forward any questions to
info@heal-medsolutions.com
Submit
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