MYNDSET Alpha Clinician Referral Program

Thank you for your interest in our early access program.

The Clinician Referral Program gives early and free access for up to 30 days for patients referred by clinicians in our healthcare network.

To benefit from the access to the program you will need to agree with the Terms and Conditions and Privacy Policy set by MYND Therapeutics Inc. Please read them carefully before you submit your application.

Code

* this code will be unique to each medical clinic.

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Doctor’s Name

Doctor’s Office Phone Number

Name of Clinic

*By clicking SUBMIT, you agree to our Terms and Conditions and Privacy Policy.

Accepts Privacy Policy and Terms And Conditions

I agree to the Terms and Conditions and Privacy Policy of MYND Therapeutics Inc.