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Apply as a Patient

Requirements for Online Application

If you decide to apply for this study, you will need to fill the following form.

A referral letter from a primary licensed healthcare provider is also necessary in order to submit the online application to the UDN.
This referral letter must include:

  1. Pertinent medical problems and prior diagnoses;
  2. Medical records of physical examinations, hospitalizations, pertinent office visits, specialist consultations;
  3. Laboratory test results;
  4. Imaging on disks;
  5. Biopsy slides when available;
  6. Video of speech, gait, hand movements when impaire

FORM ON LINE

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