Name
*
Email
*
Phone
*
What best describes your current mobility condition?
*
Select an option
Fully mobile, but experiencing chronic pain
Partially mobile / need support while walking
Bedridden or dependent on caregiver
Recovering from surgery or accident
What kind of health issue are you primarily facing?
*
Select an option
Genetic / hereditary condition
Accident or trauma-related injury
Organ dysfunction (kidney, liver, heart, etc.)
Autoimmune or syndrome condition
Other chronic issue (please specify)
How long have you been struggling with your condition?
*
Select an option
Less than 6 months
6 months – 1 year
1–3 years
More than 3 years
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