It's Up to Us

YES, I would like to help Medtronic with its advocacy efforts to ensure appropriate access to therapies and medical technology for all patients in need. I understand in order to receive relevant information I will be on Medtronic’s mailing list.

By completing and submitting this form you are granting Medtronic permission to contact you about advocacy initiatives through vehicles such as newsletters and action alerts. Your contact information will be added to the “It’s Up to Us” mailing list.

*Required Fields

Salutation:
*First Name:
*Last Name:
Home Address:
City:
State:
Zip:
*Phone Number:
*Email Address:
Business Address: (if applicable)
City:
State:
Zip:
Business Phone
Facility Name: (if applicable)

*I am a:
	Clinician	Hospital/Surgery Center Representative
	Patient	Clinic/Facility Staff
	Caregiver	Other interested individual

*I am willing to:
	Write a letter/e-mail	Contact and/or meet with my legislator
	Make a phone call	Testify at a public hearing
	Tell my story	Promote this program; send me materials

*As a patient, caregiver, clinician or facility I am involved with the following treatment:
	Neurostimulation for pain	Modern Spinal Fusion
	Intrathecal Drug Delivery System For Pain	Advanced Bone Graft Technology
	Deep Brain Stimulation Therapy	Sacral Nerve Stimulation
	Intrathecal Drug Delivery System for Severe Spasticity	Gastric Electrical Stimulation
	Minimally Invasive Spinal Therapy	Other Please Specify

*What type of insurance provided coverage for your medical device?
	Medicaid	Private Payor
	Medicare	Other Please Specify
	Workers' Compensation	Other Please Specify
Other Comments - Information You Would Like to Share :

Medtronic respects the confidentiality of personal information. We assure you that we will not share your personal information, except as otherwise noted in our privacy policy located at www.medtronic.com/statements/privacy.html. To obtain a copy by mail, please call 1-800-468-9749.

To remove your name from Medtronic’s mailing list at any time, you may e-mail us at preservingtherapyaccess@medtronic.com, call us Toll Free at 1-800-468-9749, or send a request in writing to: Medtronic “It’s Up to Us”, 7000 Central Avenue NE, RCE 395, Minneapolis, MN 55432-3576

*I am a:

*I am willing to:

*As a patient, caregiver, clinician or facility I am involved with the following treatment:

*What type of insurance provided coverage for your medical device?

Other Comments - Information You Would Like to Share :