European Congress of Radiology MERIT MEDICAL Attendee InformationName* First Last PhoneEmail* Your Position at Facility* Consultant Fellow Hospital Administration / Executive Lab Manager Marketing / Office Nurse Other Pharmacist Physician Referring Physician Resident Supply Chain / Procurement Surgeon Tech Medical Specialty* Adolescent Medicine Allergy & Immunology Anesthesiology Breast Radiologist Breast Surgery Cardiology Cardiothoracic Surgery Clinical Neurophysiology Colon & Rectal Surgery Critical Care Electrophysiology Emergency Care Emergency Medicine Endocrinology Gastroenterology General Practice General Surgery Geriatrics Hospice & Palliative Medicine Infection Control Infectious Disease Intensive Care Internal Medicine Interventional Cardiology Interventional Nephrology Interventional Oncology Interventional Pain Management Interventional Radiology Neonatology Nephrology Neurointerventional Radiology Neurology Neuroradiology Neurosurgery Oncology Orthopedic Spine Surgery Orthopedics Pain Management Pediatrics Pulmonology Radiation Oncology Radiology Supplies Surgery Thoracic Surgery Transplant Surgery Ultrasound Vascular Access Vascular Medicine Vascular Surgery Facility InformationFacility Name* Facility Location - Country*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsOpt-In & Privacy InformationEmail 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.NameThis field is for validation purposes and should be left unchanged.
