Venous Insufficiency Education Course Interest Form

Course Type*

Hidden

Future course notification?

yes

Course Date*

Course Location*

Attendee Information

Name*

First Last

Phone*

Email*

Facility Information

Facility Name*

Facility Location - Country*

Experience & Other Information

Job Category*

Medical Professional
Healthcare Industry

Healthcare Specialty*

Please provide detail if you selected "Other" above*

Treatment modality currently used (if any)

Please provide detail if you selected "Other" above*

Superficial endovenous treatment experience

0-10 cases
11-50 cases
51-100 cases
101+ cases

ClariVein OC Experience

Yes
No

How many cases?*

0-5 cases
6-10 cases
11+ cases

How were you referred to us?

Opt-In & Privacy Information

Email Communications*
I would like to receive personalized information on products, events, news and offers from Merit Medical Systems, Inc, 1600 West Merit Parkway, South Jordan, UT 84095 by email.

Opt-In Email*

Yes
No

I hereby further consent to a processing of my personal data which I inserted in the data fields above for these purposes, including profile building, to better tailor the advertising information to my personal interests based on my previous and predicted choices.

You may revoke your consent at any time. This does not affect the lawfulness of the processing up to the time of the revocation. Furthermore, you have the right to object to the processing of your personal data for direct marketing purposes at any time. For more information regarding your personal data and your rights, please see our Privacy Notice.

Merit Medical Nederland B.V. ("Merit Medical") intends, with your consent, to create video recordings ("Record") during the webinar for which you have registered: ThinkVeins on 11 August 2020. You and other attendees of this event may ask questions during and after the presentation of the clinical specialist, which will be video and audio recorded (as well as the presentation, which will be recorded).

After the conduction of the webinar, Merit Medical would like to share this Record with all attendees of the webinar and use this Record for further training as described under Clause 2.

1. Identity and contact details of the controller
The controller responsible for the processing of your data is Merit Medical Nederland B.V., tel.: +31 43 3588222, email: [email protected]

2. Purposes of the processing
The creation, recording, showing to all attendees and other persons (in particular, staff of Merit Medical) for training purpose of the Record and the associated processing of your personal data serve the following purpose: to promote the Merit Medical brand and its products and/or services to the general public, and to potential advertisers and customers of Merit Medical and for training purposes.

3. Relevant data categories
The personal data referred to below has to be provided in order to be able to record and present the Record for the purposes referred to under Clause 2: (i) video and audio recordings (which may include special categories of personal data in particular health data) (ii) name.

4. Transfer to third countries
With your consent your personal data will be stored and/or transferred to and will be stored in a third country (outside the EU/EEA), such as in the US, which does not provide a level of data protection equivalent to EU data protection law.

5. The voluntary nature of disclosure
Consent to the publication of the data categories named under Clause 3 is voluntary and not legally or contractually prescribed or necessary. The only result of any refusal of your consent is that Merit Medical will anonymize the Record, so that you cannot be identified or the Record may not be used by Merit Medical for the above purposes.

6. Right of withdrawal
You have the right to withdraw your consent free of charge at any time, e.g. by email to: [email protected] Withdrawal of consent will not affect the lawfulness of processing based on consent prior to the withdrawal of consent.

7. Further information
Further information on data protection and on your rights is available in our privacy statement in relation to Records for Attendees in Annex.

Declaration of Consent and Granting of Rights

By clicking on "Consent to personalized recording" I consent to the processing of my personal data in accordance with the above remarks, in connection with creation, recording and sharing of the Record. This also includes the storage in/ transfer to third parties as described above, which does not provide a level of data protection equivalent to EU data protection law. This also applies where this data relates to special categories of personal data (e.g. health data).

In addition, I hereby consent to the use – for the relevant purposes – of video- and audio recordings created during production of the Record. In particular, I consent to showing the Record to other persons for training purposes and to an adjustment and/or amendment as part of the creation of the Record ahead of showing the Record to other persons.

Note:
If you click on "Consent to recording that will be anonymized" we will create a recording, but we will anonymize it so that you cannot be identified before we use it.

Consent*

Consent to personalized recording
Consent to recording that will be anonymized

* Required. If you do not provide this personal data we may not be able to (fully) respond to your request.

Annex Privacy Notice

Hidden

Status

Phone

This field is for validation purposes and should be left unchanged.