REQUEST INFORMATION DBS FOR EPILEPSY

Form goes here once we get an Eloqua form requirements document.

First Name*
Last Name*
Email*
Zip Code*
By completing and submitting this form, you are granting Medtronic permission to add your personal information, including your contact information and basic healthcare information, to its patient database, and to share that information with Medtronic representatives and health care providers as appropriate. We may conduct analyses on information collected in order to make improvements to and provide training on our operations, products, services, and customer communications. Medtronic may de-identify data collected, combining it with data collected from other sources. Lastly, information provided may be shared with your physician for treatment considerations or other purposes. You also agree to being contacted by Medtronic in the future by mail, telephone or by non-password protected electronic communications, such as emails or text messages. Medtronic may exchange information with you regarding our products or services, inquire about your experience, or determine how Medtronic can support you through your journey.

Medtronic respects the confidentiality of your personal information. If at any time you wish to revoke all or part of this permission, you can email us to rs.neuropatientsupport@medtronic.com or send a request in writing to: Medtronic Patient Support, 7000 Central Ave NE, RCE 230, Minneapolis, MN 55432. This permission will expire 10 years after the date of your signature.*

*If you live in Maryland, the consent expires automatically in one year. We may contact you then to see if you would like to renew it.

I agree*

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