SUPPORT LINK ENROLLMENT FORM Percutaneous Tibial Neuromodulation (PTNM)
With enrollment from you and consent from each of your patients, our Support Link team will call, text, or email your patients at specific milestones during their therapy to:
By submitting this form, you and the primary contact for your office are verifying a Medtronic representative has explained Support Link to you, and you would like to enroll your office and consented patients.
You also understand how, when, and where Medtronic Support Link will refer patients to you or other clinicians (see patient referral information below) if they are interested in exploring other advanced therapies.
Once you have submitted the enrollment form, you will receive a confirmation email from Support Link representatives.
*Indicates Required Field
After your practice is enrolled, individual patient consent is required for the Support Link program.
For your patients considering or receiving PTNM for Bladder Control delivered by the NURO system, your office staff should ask for signed patient consent during initial patient appointments and thereafter if consent was not received during the first appointment.
Patients can consent directly online at medtronic.com/signup.
If preferred, printed patient consent forms can be found in the PTNM guidebook for patients at medtronic.com/bladderresources.
Completed patient consent forms should be submitted to Medtronic for processing and enrollment to one of the following:
Email: email@example.com Fax: 1-800-892-7708 Mail: 7000 Central Ave. NE, RCE230, Minneapolis, MN 55432-9987
Eligibility Requirements: Patients must be receiving PTNM with the NURO system to be eligible for Support Link. Patients receiving the therapy with other devices are not eligible.
For questions about the PTNM Support Link program email firstname.lastname@example.org.
Sacral Neuromodulation delivered by the InterStim™ system for Urinary Control is indicated for the treatment of urinary retention and the symptoms of overactive bladder, including urinary urge incontinence and significant symptoms of urgency-frequency alone or in combination, in patients who have failed or could not tolerate more conservative treatments.
Contraindications: Diathermy. Patients who have not demonstrated an appropriate response to test stimulation or are unable to operate the neurostimulator.
Safety and effectiveness have not been established for bilateral stimulation; pregnancy, unborn fetus, and delivery; pediatric use under the age of 16; or for patients with neurological disease origins. The system may be affected by or adversely affect cardiac devices, electrocautery, defibrillators, ultrasonic equipment, radiation therapy, MRI, theft detectors/ screening devices. Adverse events include pain at the implant sites, new pain, lead migration, infection, technical or device problems, adverse change in bowel or voiding function, and undesirable stimulation or sensations, including jolting or shock sensations. Patients should be assessed preoperatively for the risk of increased bleeding.
USA Rx Only. Rev 0517
Percutaneous Tibial Neuromodulation delivered by the NURO™ system is intended to treat patients with overactive bladder and associated symptoms of urinary urgency, urinary frequency, and urge incontinence.
Contraindications: Do not use on patients with pacemakers or implantable defibrillators, patients prone to excessive bleeding, patients with nerve damage that could impact either percutaneous tibial nerve or pelvic floor function, or on patients who are pregnant or planning pregnancy.
Warnings/Precautions/Adverse Events: Do not use if the skin in the area of use is compromised. Exercise caution for patients with heart problems. Adverse events are typically temporary, and include mild pain, minor inflammation and bleeding near treatment site.
For full prescribing information, please call Medtronic at 1-800-328-0810 and/or consult Medtronic's websites at www.medtronic.com.
Product technical manual must be reviewed prior to use for detailed disclosure.
USA Rx only. Rev 0517