Registration form for medical organizations

Medical organizations clients (commercial and charitable non-profit: hospitals, rehabilitation centres, doctors)

Can we kindly ask you to complete the following registration form.
Please provide us with licensee details, name and contacts of the responsible person and, if possible, give your opinions on our questions from the feedback and user experience section.

Your opinion is very important to us, and we greatly value your feedback!

A. Licensee

  • 4. Full Address




B. Contact Person

C. Problem Definition

* - More details are better. It allows us to take a positive decision about issuing a free license for the private / non-commercial use. We recommend not to leave these fields blank.

D. Additional Information

  • 5. Does your organization/hospital/rehabilitation facility have any completely paralyzed patients (Locked-in Syndrome, Guillain Barre Syndrom, Quadriplegia, etc.)?

E. Select products

  • ECTtracker
  • ECTkeboard
  • ECTmouse
  • ECTcamera
  • ECTlistener
  • ECTmorse

F. Feedback and user experiencee

  • 1. Did you already have a chance to try our products or read about them?
  • Agree
  • Agree
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