Please answer the following
What was the result of your last HbA1c test:
*
When was your diabetic neuropathy diagnosed:
*
Do you still suffer this neuropathy despite your medication:
*
Are you taking pregabalin or gabapentin to treat your pain:
*
Are you taking Tramadol or any other opiate:
*
Do you have any surgery planned in the next 2 months:
*
Have you read the eligibility criteria and do you live within a 30 mile radius of a participating centre:
*
Your details
Date of birth:
***
*
Type of diabetes:
*