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?*

YesNo
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?*

YesNo
Do you perform PACK-CXL for the treatment of corneal infections? *

YesNo
If yes: how many corneal ulcers do you see per month?*
Would you be interested in 1 or more CXL devices?*

12Other
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? *

YesNo
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?*

YesNo
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*

I consent to receiving email correspondence about EMAGine's products and services.
Please verify that you are human*
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