SUPPORT LINK ENROLLMENT FORM Percutaneous Tibial Neuromodulation (PTNM)

Support Link Patient Benefits

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:

Discuss symptom relief, provide encouragement, and manage expectations
Encourage patients to complete the 12-week therapy
Answer non-clinical questions about PTNM for Bladder Control delivered by the NURO system
Point patients to other available Medtronic resources

Get your practice started

Complete the Clinician enrollment form, one time only

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

Patient referral information

The primary goal of Support Link is to guide patients on their journey, but some of your patients may be interested in considering other advanced therapies. This includes sacral neuromodulation (SNM) delivered by the Medtronic InterStim™ System.

How would you like your patients to be referred to SNM? (Check which referral you prefer. Choose only one option.)

By completing and 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 as you indicated in the form above if they are interested in exploring other advanced therapies.*

PATIENT CONSENT

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: rs.neuropatientsupport@medtronic.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.

QUESTIONS

For questions about the PTNM Support Link program email rs.neurogupatientsupport@medtronic.com.