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Please complete the following form to request further information. These details will be sent to Doctor Bellamy who will respond to your request in due course.


Please enter your personal details First name, last name, country and email address are required

First Name:
Last Name:
Company Name:
Email Address:
Phone number:		Fax number:
Address:
Country:		Postal/ Zip Code:


Please indicate your professional classification Please select all that apply.

Biotechnology Company Contract Research Organisation (CRO) Health Management Organisation (HMO) Library Occupational Therapist Orthopaedic Surgeon Pharmaceutical Company	Physiotherapist Publishing Company Rehabilitation Specialist Rheumatologist Student - Postgraduate Student - Undergraduate Other


Intended Application
Clinical Practice Clinical Research Instrument Development	Education Other


Details of intended application
Protocol number and protocol title
Total number of patients to be studied
Period under study for each patient
Total period of use of index
Number of visits per patient during study period


Source of funding
Commercial/ Industry Peer Review Private - Please specify Unfunded


Details of instrument required
Type:	WOMAC^® 3.1 Index	AUSCAN^™ 3.1 Index	OGI^™ 8.0
Scale:	Likert (5 point)	Visual Analog (100mm)	Numerical Rating Scale (11-point)
User Guide:	WOMAC^® Yes No	AUSCAN^™ Yes No

Languages Please select country and dialects

Argentina			Korea

Australia			Latvia
			- Latvian
			- Russian

Austria			Lebanon

Bangladesh			Lithuania
			- Lithuanian
			- Russian

Belgium			Malaysia
- Flemish			- Cantonese
- French			- English
			- Malay
			- Tamil

Brazil			Mexico
- Japanese
- Portuguese

Bulgaria			Moldova
			- Romanian
			- Russian

Canada			Netherlands
- English
- French

Chile			New Zealand

China			Norway

Colombia			Peru
			- Japanese
			- Spanish

Costa Rica			Philippines
			- Cebuano
			- English
			- Tagalog

Croatia			Poland

Czech Republic			Portugal

Denmark			Puerto Rico

Dominican Republic			Romania

Ecuador			Russia

Egypt			Saudi Arabia
			- Arabic
			- English

Estonia			Serbia
- Estonian
- Russian

Finland			Singapore
			- English
			- Malay
			- Mandarin

France			Slovakia

Georgia			Slovenia

Germany			South Africa
			- Afrikaans
			- English
			- Sesotho
			- Setswana
			- Xhosa
			- Zulu

Greece			Spain

Guatemala			Sweden

Hong Kong			Switzerland
			- French
			- German
			- Italian

Hungary			Taiwan

Iceland			Thailand

India			Turkey
- Bengali
- English
- Telugu
- Urdu
- Gujarati
- Hindi
- Kannada
- Malayalam
- Marathi
- Oriya
- Punjabi
- Tamil

Iran			UAE
			- Arabic
			- English

Ireland			UK

Israel			USA
- Arabic			- English
- Hebrew			- Florida
- Russian			- Spanish

Italy			Ukraine
			- Ukrainian
			- Russian

Japan			Venezuela

Request Further Information

Please enter your personal details

Please indicate your professional classification

Intended Application

Details of intended application

Source of funding

Details of instrument required

Languages