A: Inscription des personnes paralysés
A: Registration of the paralyzed
Sign in to Google to save your progress. Learn more
Email *
Nom *
Last name
Prénom *
First name
Ville et code postal *
City and zip code
Adresse *
Address
Numéro de téléphone *
Phone number
De quelle nationalité êtes-vous? *
What is your nationality?
Vous êtes? *
You are?
Required
De quand date votre lésion médullaire ? *
When did your spinal cord injury date?
Quel âge avez-vous? *
How old are you?
Votre paralysie est complète où incomplète? (ASIA) *
Is your paralysis complete or incomplete? (ASIA)
Pratiquez-vous une de ces activités physiques régulièrement ? *
Do you participate in any of these physical activities regularly?
Oui/Yes
Non/No
Kinésithérapie (Physiotherapy)
Verticalisation (Verticalization)
Autre activité sportive (Other sports activity)
Seriez-vous prêt(e) à prendre part à une nouvelle étude clinique avec la graisse activée et l’EPO ? *
Would you be ready to take part in a new clinical study with activated fat and EPO?
*
So that Neurogel En Marche can continue the development of this therapy, would you like to participate financially monthly or annually for a cure for the paralysis?
So that Neurogel En Marche can continue the development of this therapy, would you like to participate financially monthly or annually for a cure for the paralysis?
J'accepte de recevoir la newsletter Neurogel En Marche ainsi que des informations par courriel concernant les futures démarches de notre association. *
I agree to receive the Neurogel En Marche newsletter as well as information by email concerning the future steps of our association.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.