Wire-Free Tumor Localization Education Form

Course Type*

Future course dates?

yes

Course Date*

YYYY

MM

DD

Course Location*

Attendee Information

Name*

First Last

Phone*

Email*

Facility Name*

Facility Country*

Facility US Location*

City * State * ZIP Code *

Type of Facility*

Academic/Teaching Institution
Private/Community based

Your Position at Facility*

Current Localization Technology

Estimated number of breast conservation cases/month

0-10
11-25
26-50
51+

Have you evaluated any technologies aside from what you’re currently using?

How were you referred to us?

Opt-In & Privacy Information

Opt-In - Course Interest

I'm interested in receiving more information on related courses from Merit Medical.

Opt-in - Email Communications Interest

I'm interested in receiving e-mail about news, products, and events from Merit Medical.

Privacy Acknowledgement*

We process your personal data provided by you to respond to your request. For more information regarding your personal data and your rights, please see our Privacy Notice.

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.

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

Healthcare Specialty

Status

Physician Education Course Interest Form