Inspire - Vertiflex™

Nominee Information

Name*

First Middle Initial Last

ZIP Code*

Phone*

Email*

Gender*

Year of Birth*

Before the Vertiflex Procedure, where were you experiencing pain?*

(Select all that apply)

One leg
Both legs
Back
Hip
Foot
Other

Please specify other pain

Before the Vertiflex Procedure, did you have any previous back procedures?*

(Select all that apply)

Laminectomy
Fusion
SCS
None
Other

Other previous back procedures

Who was your Vertiflex Procedure physician?*

Date of Vertiflex Procedure*

How many levels?*

Were you referred by your physician?*

Yes
No

Were you referred by a Boston Scientific representative?*

Yes
No

Please explain the reason(s) this patient would be an exceptional representative of Boston Scientific's Vertiflex Procedure.*

Would this patient be able to communicate clearly and effectively to other prospective Vertiflex Procedure patients?*

Yes
No
Not sure

Additional information you would like to share regarding this potential Patient Ambassador?

Communication Preferences

Which days and times would you be able to speak to a potential patient?

Day of week*

(Select all that apply)

Any day
Weekdays
Weekends

Time of day*

(Select all that apply)

Any day
Morning (9am – 12pm)
Afternoon (12pm – 5pm)
Evening (5pm – 9pm)

For patient’s nominating themselves: By clicking Submit, I consent to Boston Scientific’s collection and usage of my personal and health information to receive emails and/or be contacted by a Boston Scientific representative regarding the Patient Ambassador Program and purposes described in the Privacy Policy.

For nominations on behalf of a patient: By clicking Submit, I consent that the patient nominee is aware and consents to Boston Scientific’s collection and usage of their personal and health information to receive emails and/or be contacted by a Boston Scientific representative regarding the Patient Ambassador Program and purposes described in the Privacy Policy.

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Nominee Information

Communication Preferences