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MiracleFeet Prospective Technical Assistance Partner Application
General Information
Clinic Data
Support Request
Personal Information
Name
Profession
Date
Clinic Information
What is the name and address, including country, of the clubfoot clinic where you work?
Clinic Name
Clinic Address
What is your role in this clubfoot clinic?
Any potential agreement must be signed by the accountable manager responsible for the clubfoot clinic.
Please describe the clubfoot services you provide:
Where did you receive your clubfoot training?
Please provide the contact details (Name and Email/WhatsApp number) of the doctor who performs tenotomies at your clubfoot clinic:
What scoring method do you use at your clinic to assess a clubfoot?
If you are human, leave this field blank.
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