REQUEST INFORMATION DBS FOR EPILEPSY

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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.

Please read our complete privacy policy here: http://www.medtronic.com/us-en/privacy-statement.html.

To receive a copy of this consent, please call 1-800-872-8287, or email us at rs.neuropatientsupport@medtronic.com. Let us know how you would like to receive it (email, mail,or fax).

^†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.

*Message and data rates may apply. Text STOP to 69301 to stop receiving Medtronic therapy reminders. Compatible carriers include: Verizon Wireless, AT&T, Sprint, Boost, Virgin Mobile USA, TMobile, Metro PCS. Medtronic respects your right to privacy. T-Mobile is not liable for delayed or undelivered messages.

**It is important to provide your email address as communications will be sent to you electronically.

Your information will be used and protected in accordance with our privacy statement.