Expanded Access Registration Questionnaire

Thank you for participating in this registration survey, which helps WST gauge interest in our upcoming Expanded Access Program (EAP).

Due to regulatory concerns, the program will first be available to diabetic peripheral neuropathy patients, followed by other types of neuropathy.

It's crucial to understand the needs of all potential EAP participants to implement the program effectively and efficiently.

All requested information is voluntary, will only be used to inform the EAP, and will not be sold to any other party.

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Name *
Email Address *
Are you 18 years of age or older? *
Which state do you reside in? *

Have you been formally diagnosed with peripheral neuropathy?

 *
What type of neuropathy do you have? *
If you have DPN, what type of diabetes do you have?
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Do you have a referring physician who agrees to provide your medical history (e.g., diabetes and peripheral neuropathy) to the prescribing doctor in the WinSanTor EAP Network?  

EAP Network: A group of licensed physicians who will facilitate the transfer of your medical records, review them, verify your eligibility for the EAP program, and complete the required paperwork for your participation in this trial.  
 *

Do you have access to a computer or smartphone to use the EAP Patient Portal?

Patient Portal: A secure online platform, protected by a username and password, where you will provide informed consent to participate in this program and report on the side effects and benefits of WST-057 during the 6-month period.

 *

Do you agree to sign an informed consent form to participate in this program through the WinSanTor EAP Portal?

 *
Are you willing to apply WST-057 daily for at least six months, along with moisturizer as needed? *
Would you be interested in volunteering to apply it for up to a year?
*

Do you agree to log into the WinSanTor EAP Portal at scheduled times to report any updates or changes to your DPN symptoms and side effects?

 *

Do you agree to cover the cost of at least six months' supply of WST-057 (~$1,980 USD or $330 per bottle)?

 *

Donate to Provide Relief for Peripheral Neuropathy Patients

Please support us by donating to our GoFundMe campaign to help launch this program: https://gofund.me/78e91cdb
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