Register for a Medtronic Radio Frequency Therapy seminar

1. First name: (required)
2. Last name: (required)
3. Street address: (required)
4. Street address:
5. City: (required)
6. State/Province: -- Select One -- AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NV NH NJ NM NY NC ND NE OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY (required)
7. ZIP/Postal code: (required)
8. E-mail: (required)
9. Phone: (required)
10. Which seminar would you like to attend? *

    	Seminar:	Dr. Robert Badalament Dr. Sheryl Wissman Dr. Andrew Madak
    	Date:	March 18, 2010 6:30 pm
    	Location:	Crittenton Hospital Medical Center Classroom 2N (A & B) 1101 West University Drive Rochester, MI 48307

    	Seminar:	Dr. Robert Badalament Dr. Sheryl Wissman Dr. Andrew Madak
    	Date:	March 25, 2010 6:30 pm
    	Location:	Crittenton Hospital Medical Center Classroom 2N (A & B) 1101 West University Drive Rochester, MI 48307

    	Seminar:	Dr. Juan Premoli
    	Date:	April 6, 2010 5:30 pm
    	Location:	UroMedix 603 N. Flamingo Road Pembroke Pines, FL 33028

    	Seminar:	Dr. David G. Heiser
    	Date:	April 7, 2010 6:30 pm
    	Location:	Acc Auditorium 1330 Mercy Drive NW Canton, OH 44708

    	Seminar:	Dr. Michael Cunningham
    	Date:	April 8, 2010 6:30 pm
    	Location:	Central Ohio Urology 941 Chatham Lane, Suite 110 Columbus, OH 43221

11. Will a guest attend the seminar with you? Yes
    No

    Please provide first and last name of your guest:

    First name:

    Last name:

12. Have you been diagnosed with symptomatic enlarged prostate, also known as benign prostatic hyperplasia (BPH)? Yes
    No
13. Are you considering the RF Therapy procedure? * Yes
    No
14. Where did you hear about Medtronic RF Therapy? Friend
    Family
    Doctor
    Urologist
    Television
    Radio
    Newspaper
    Magazine
    Poster
    Seminar/Event
    Other
15. Would you like to receive a packet of information about Medtronic RF Therapy? * Yes
    No
    The packet includes a free video in DVD format. Would you like the video in VHS (video tape) format instead? * Yes
    No

You will receive the information in about 5 business days. Thank you for registering for this educational seminar.

By completing and submitting this form, you are granting Medtronic permission to add your contact information to its database for Medtronic RF Therapy and consent to receiving future materials about Medtronic's products and services.

Important: Medtronic respects the confidentiality of personal information. We assure you that we will not share your responses or personal information, except as otherwise noted in our Privacy Policy.

To remove your name from Medtronic's mailing list at any time, e-mail or send a request in writing to:

Medtronic Inc.
Radio Frequency Therapy
710 Medtronic Parkway, X-184
Minneapolis, MN 55432