Pre-Screening Questionnaire

Please complete this pre-screening questionnaire to see if you qualify for the IDCT trial.

Note: Your answers to the following questions will only be used to determine if you meet preliminary criteria for the clinical study. If you meet the preliminary criteria, you will have the option to enter personal information if you would like to be contacted by a representative from DiscGenics. Your answers to the questions may be collected in aggregate, but will not be associated with your personal information.