Registration form - AMEDS Centrum

Registration

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If you are interested in CCSVI testing and treatment at AMEDS Centrum and would like to be placed
on our preliminary registration list, please fill out the form below.
We will contact you as soon as possible.

Firstname: *

Surname: *

Country: *

Country code:Phone number:

E-mail address: *

E-mail address (retype): *

Comments:

Please share with us how did you learn about AMEDS Centrum:

please specify who:

please specify the source:

The processing of personal data:
By sending the above information, you consent to the processing of personal data included
in the questionnaire for the purposes of the registration process (in accordance with
the Polish Act of Law dated 28/08/1997 about Data Protection, Official Journal no 133 item 883).

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