Form Requested as a Professional

Information Request Form for Healthcare Professionals

BruxApp Cloud is a platform in the medical and healthcare field, and access is permitted only to physicians, dentists, or physiotherapists.

For this reason, we need to collect your personal information and professional qualifications to provide you with information about the platform.

Please note that, in the event of subscription, you will be required to submit a copy of your degree certificate.

First Name:

Last Name:

Email:

Country:

City:

Type professional:

Place of Graduation:

Year of Graduation:

University:

Birth date (dd/MM/yyyy):

Newsletter:

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Agree Privacy Policy:

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