If you want tele-consultation, please fill in the basic information and send it to us. We will contact you for necessary guidance.

Primary information Name …………………………………………………………………………………..  Age / Gender …………………………………..     Address : City / State ......................................................... ................................................................... ...    Mobile Number ……………………………………………………………………………………..    Email Address ……………………………………………………………………………………   Date of Spinal cord injury / disease .................................. ............         Level of spinal cord injury ..................................... ......................       Hand function :  Yes / OK ............  Not adequate for CIC ...............                             Current method of bladder management : ………………………………………………………………………… ...

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