Test d’éligibilité

Step 1 of 6

Country of Residence(Required)

How old are you?(Required)

Please enter a number from 1 to 100.

What treatment are you currently receiving?(Required)

What are your genes and symptoms?(Required)

Based on your answers, your profile appears to be a good fit for the SCP. Please fill out the contact form to be contacted.

Name(Required)

First name(Required)

Date of birth(Required)

Name and contact details (email or telephone) of the referring physician responsible for monitoring the condition: Neurologist, or failing that, a general practitioner:

How can I contact you?(Required)

E-mail address

Phone

Phone(Required)

E-mail(Required)

Languages spoken(Required)

Country of Residence(Required)

Your current treatment

Year of onset of the illness(Required)

Please enter a number from 1900 to 2024.

Who suggested the SCP for you?

Comment êtes-vous arrivés sur la page AzurDBS ?(Required)

Autre :

What do you expect from this operation?(Required)

Note : After receiving this form, we will get back to you within 3 weeks and will ask you to provide us with more medical information for an initial assessment. You will be asked to:

A short video illustrating your symptoms (1 min maximum – accepted via smartphone)
Medical documents illustrating your state of health:
- MRI report (required)
- Referring physician's letter (required)
- Blood test results from the last 3 months (optional)
A photo of each document taken with a smartphone is acceptable.

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Eligibility status

Eligibility test