NEUROSPHERE™ VIRTUAL CLINIC

PATIENT ENROLLMENT PORTAL

Sign Up for Abbott NeuroSphere™ Virtual Clinic

By completing this form, you are confirming you have received information about NeuroSphere™ Virtual Clinic, and would like to have a member of the Abbott team enroll you for Virtual Clinic access.

FIRST NAME

LAST NAME

PHONE NUMBER

ZIP CODE

E-MAIL ADDRESS

IMPLANTING PHYSICIAN NAME

WHAT ABBOTT THERAPY DO YOU HAVE?

By registering, I authorize Abbott to keep in its databases the information I’ve provided and to use such information for the following purposes:

To enroll me for NeuroSphere™ Virtual Clinic access within the St. Jude Medical™ Patient Controller App
If I have an Abbott device, to contact me for therapy support purposes

I also consent to the storage of my information in the U.S. While Abbott may disclose my information to its contracted third parties in connection with its use of the data for these purposes, Abbott will not sell or transfer my name or contact information to any third party for its marketing use. Further, Abbott shall use and maintain my information consistent with its privacy policy at https://www.abbott.com/privacy-policy.html I can opt out of receiving information and revoke my consent at any time by following the instructions in the correspondence that I receive.

*Enroll me for Virtual Clinic access.

By clicking "yes" below, I affirm that:

I am of legal age to enter into this agreement; and
I am I am agreeing to this agreement on my own behalf or on behalf of another individual for whom I have actual authority to legally bind that individual to this agreement

Yes

MAT-2103072 v1.0

You are about to exit the Abbott family of websites for a 3rd party website

Links which take you out of Abbott worldwide websites are not under the control of Abbott, and Abbott is not responsible for the contents of any such site or any further links from such site. Abbott is providing these links to you only as a convenience, and the inclusion of any link does not imply endorsement of the linked site by Abbott.

The website that you have requested also may not be optimized for your screen size.

Do you wish to continue and exit this website?

test

True

accessibility

Unless otherwise specified, all product and service names appearing in this Internet site are trademarks owned by or licensed to Abbott, its subsidiaries or affiliates. No use of any Abbott trademark, trade name, or trade dress in this site may be made without the prior written authorization of Abbott, except to identify the product or services of the company.

YES NO

accessibility

test

YES NO

accessibility