MEDTRONIC | COLORECTAL PHYSICIAN FINDER

First Name *

Last Name *

Email Address *

FACS Board Certified?

FACRS Board Certified?

Please List Surgeon Board Certifications

Estimated Annual Number of Colorectal Procedures

Hospital Affiliation *

Practice Name *

Address 1 *

Address 2

City *

State or Province *

Zip or Postal Code *

Practice Phone Number *

Practice Email Address

Practice Website

Do you need to add another practice?

Second Practice Name

Second Practice Address 1

Second Practice Address 2

Second Practice State or Province

Second Practice Zip or Postal Code

Second Practice Phone Number

Second Practice Email Address

Second Practice Website

Do you need to add another practice?

Third Practice Name

Third Practice Address 1

Third Practice Address 2

Third Practice State or Province

Third Practice Zip or Postal Code

Third Practice Phone Number

Third Practice Email Address

Third Practice Website

I agree to receive Physician Finder Emails from Medtronic. *

I have read and agree with the Terms and Conditions. (US) *

*By completing and submitting this form, you agree to accept the Medtronic criteria policy and release agreement. Your information will be used and protected in accordance with our privacy statement.

© 2020 Medtronic. All rights reserved. Medtronic, Medtronic logo and Further, Together are trademarks of Medtronic. All other brands are trademarks of a Medtronic company. 11/2020 – US-SE-2000240 – [WF 4865604]

JOIN THE MEDTRONIC.COM

COLORECTAL PHYSICIAN FINDER