Patient Registry Application

Screener

Please fill out the brief screener below to determine whether you are eligible to submit a Patient Registry application.

1/3

Are you currently a legal adult (at least 18 years old and the age of majority in your state)? *

Yes

2/3

Are you a U.S. citizen or permanent resident? *

Yes

3/3

Do you have any of the following conditions: quadriplegia, paraplegia, visual impairment or blindness, aphasia or the inability to speak, hearing impairment or deafness, and/or major limb amputation (affecting above or below the elbow and/or above or below the knee)? *

Yes