A Medical Approach to Autism

Thank you for your interest in Suramin.

This form is intended for individuals who would like to participate in, or receive more information about, upcoming clinical trials.

Please complete all sections as thoroughly and accurately as possible. All information provided will be kept strictly confidential and used solely to

What to expect from the SURAMIN clinical trials.

Autism severity scores dropped from 8.6 to 1.6 using Suramin.

Parents and Doctors found improvements in the following

APPLICATION

Find out if your child is qualified to participate in a SURAMIN clinical trial

Parent/Guardian Full Name:

Child's Full Name:

Child's Date of Birth:

Child's Gender:

Email*

Phone

Relationship to Child:

City & Country of Residence:

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SILVIA THEOS

+1 706 4525 573 info@drsilviatheos.com

Suramin for Autism

drsilviatheos.com

Announcement

Autism Treatment is here, Book a Doctors Visit.

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