Free Evaluation Application Form

Patient (or First) Name

Last name

Email

Confirmation Email

Birthday

Gender

Male

Female

Prefer not to say

Country

Phone

Address

How did you learn about the Xiao procedure or our hospital?

Single choice

Your responses to the following questions will be reviewed by our physicians to determine your candidacy for Xiao procedure

What type of illness do you have?

Spina Bifida/Myelomeningocele

Spinal Cord Injury/Paraplegia

Neurogenic Bladder Caused by Radical Surgery

Neurogenic bladder caused by other factors

What is your illness diagnosis and date?

Could you describe past and current treatments?

Before understanding the xiao procedure, what are your expectations for the treatment of your illness?

We value your privacy and confidentiality. Our free evaluation does not require you to provide any personal medical information. However, if you choose to share some relevant details (electronic documents) that could assist in the evaluation of your condition, you are welcome to do so voluntarily. Your trust and comfort are our top priorities. You can upload the additional electronic documents through the following methods.

File upload

Please upload any electronic documents you consider important about your condition. The file format is not limited, and the total number of files should not exceed 10.

Disclosure: We respect your privacy 100%, so the information that you provide will remain strictly confidential. Nevertheless, a copy of your message might be stored in our records as a database entry for archival purposes.

肖伝国医院

Free Evaluation Application Form

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