Intake form

Name *

Email address *

What is your age group?

What is your gender?

What is your current medical status regarding diabetes?

Please select at least one option.

Type 1 Diabetes

Type 2 Diabetes

Pre-diabetes

None

Have you been diagnosed with a diabetic foot ulcer?

What treatments have you previously used for your diabetic foot ulcer?

How did you hear about azyro?

Please select at least one option.

Doctor

Hospital

Online Search

Social Media

Referral

What is your primary concern regarding wound care?

Additional questions or comments

Which service or services are you interested in?

Please select at least one option.

Advanced bioelectronic treatment

Infection control enhancement

Comprehensive wound assessment

Address *

Azyro