Questionnaire for offer

Questionnaire for offer

Your answers help us shape a better response
Your answers provided here will help us understand what you need and will allow us to prepare a detailed offer.
Name of your practice / clinic
For example: "St. Mary's Hospital" or "Practice Dr. Kent"
Name

First NameLast Name
E-mail
Country
Do you currently perform CXL in your practice?
If yes: how many CXL treatments do you perform on average each month?
Would you also be interested in the table mount apparatus to conduct CXL in the traditional / laying down way?
Do you perform PACK-CXL for the treatment of corneal infections?
If yes: how many corneal ulcers do you see per month?
Would you be interested in 1 or more CXL devices?

Other
What does your clinic charge for a CXL treatment per eye?
US Dollars
Does your country offer health care reimbursement for CXL treatment for keratoconus?
How much do they reimburse per CXL procedure?
US Dollars
Do you perform pro bono (free) treatments if national health insurance does not cover the costs of the procedure?
If so, how many per month?
Do you have a budget in mind for the device?
US Dollars
Do you have a price range for the cost of the riboflavin kit?
US Dollars
Where would this device need to be shipped?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Do you have a date by which you would like to receive your device and riboflavin packs?

YearMonthDay
More Comments/Questions
GPDR Statement
Please verify that you are human
Should be Empty: