Contact form

Please fill out the form below to let us know which service you are interested in and how we can help you. We will contact you as soon as possible.

Name*

Surnames*

Phone number*

E-mail*

Company name

Position

Address*

Ciudad*

Provincia*

Which service are you interested in?*

Add a message or tell us more precisely how we can help you.*

If it is rehabilitation, tell us your goal and current situation (mobility, gait, balance, arm/hand, fatigue, pain, autonomy…).

Fill out only if rehabilitation therapies are required.

Main diagnosis

Only if rehabilitation therapies are required.

Time since diagnosis

Less than 3 months

3–6 months

6–12 months

1–2 years

More than 2 years

Only if rehabilitation therapies are required.

Age

Only if rehabilitation therapies are required.

Current state of mobility

She walks without assistance.

Walks with assistance (cane/walker)

Uses a wheelchair

It depends on transfer assistance

Only if rehabilitation therapies are required.

I agree that my data provided in the contact form may be processed electronically and used for the purpose of contacting me. I understand that I can revoke my consent at any time. (See the table with basic information on Data Protection included below this form).