Rep page to Register Clinical Research Request

Thank you for registering Clinical Research Requests.

Submit the completed form below to register Clinical Research Requests.

Request for Clinical Research on Avazzia medical devices
Recipient's Name*
First Last
Recipient's Email*
Company or Facility Name of Recipient*
I understand that the FDA restricts dissemination of information about new or uncleared uses.*
- Yes, Recipient is a health care professional who requested clinical research on Avazzia medical devices.
Recipient's Position or Title
Recipient's phone number
How did Recipient hear about Avazzia?
Recipient prefers the material to be provided (check preference)
- electronically
- printed and mailed (mailing address required)
- both electronically and printed and mailed (mailing address required)
Business mailing address of Recipient
Mailing address is required if material is to be printed and mailed.

Street Address Address Line 2 City State ZIP Code
Updates to Clinical Research information requested
- Send new or updated information about clinical research with Avazzia as it becomes available.
- Recipient asks not to be sent new information or updated clinical research materials.
Fulfilment status
Clinical research information was requested by a health care professional.
- It has already been provided.
- It has not been delivered. Avazzia is to send information to the Recipient.
Sales Rep or value-added reseller contact information
Sales Rep Email
Sales Rep name
Upload copy of signed Clinical Research Request Form, if available.
Max. file size: 50 MB.
Person submitting this request form, if different from the person requesting the information, the sales rep, or reseller
Email of person submitting
Name of person submitting
Download Monitor - Gravity Forms Lock

32959

Avazzia, Inc.
13140 Coit Road, Suite 515
Dallas, Texas 75240
USA

US FDA disclosure:

Avazzia medical devices are cleared as TENS for pain relief. The FDA has not approved or cleared Avazzia devices as safe or effective for any other uses.

AX-210422-02 A

Rep page to Register Clinical Research Request

Thank you for registering Clinical Research Requests.

Request for Clinical Research on Avazzia medical devices

Fulfilment status

Sales Rep or value-added reseller contact information

Person submitting this request form, if different from the person requesting the information, the sales rep, or reseller