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.