DIGITAL HEALTH ENROLLMENT

FILL OUT THE FORM BELOW

Please complete the form to ensure a smooth enrollment process.

* Indicates a required field.

Medtronic Therapy

Which Medtronic therapies are managed or implanted by your clinic?* (Check all that apply)

Practice Details

This information will be used to generate the contract and create the Efficio™ clinic name. Match the practice name and address to customer sold to address in SAP.

Please describe this practice*
(Choose one):



How does this location interact with devices?*
(Choose one)



PRACTICE ACCOUNT MANAGER (PAM)

The practice account manager will be the primary person to enroll additional users from the practice in the cloud software.

Note: Digital health enrollment details will be shared via email.

LEGAL CONTRACT SIGNEE

To gain access to the cloud software, the practice must sign a business associate agreement, terms of use, and therapy addendum(s). Please identify who should sign the contract.

MEDTRONIC REPRESENTATIVE

IT SUPPORT

If you need immediate IT or Wi-Fi assistance, call Digital Connectivity at 1-800-707-0933.