CONSENT AND AGREEMENT REFLUX TESTING AND TREATMENT

SHARE YOUR STORY CONSENT AND AGREEMENT

I agree to the following:

I consent that all the information that I provide through this “Share Your Story” form, including my personal data and my health data, will be processed by Medtronic and its affiliates for the purposes of assessing my eligibility for publication of my health story. I understand that if I do not provide consent, Medtronic will not be able to utilize the information provided.

I agree to the following:

I hereby grant Medtronic and its affiliates a royalty-free, worldwide license to use, reproduce, display, perform, modify, make available, translate, transmit and distribute the information I provided in any medium, and agree that Medtronic is free to use it for its business purposes.

I understand and agree that if my story is selected for publication; my story may be featured in Medtronic promotional materials and shared with the media.

• In such case, I consent to Medtronic and its affiliates to engage in the following data processing activities:
  • Creation and modification of photographs, video and or audio recordings of me and references to my name, age, gender, occupation, and medical condition.
  • Use of the images and data in any materials produced in any medium for Medtronic’s advertising and marketing activities such as brochures, reports, promotional videos and websites for the purposes of portraying a patient who has been treated with a product or therapy.
  • Publication, distribution and transfer to third parties wherever located of the images and data.

• I agree that all materials in which my information will be included, will be the property of Medtronic or its affiliates and that I will have no interest in any intellectual property rights which may exist in such materials.
• I understand that Medtronic excludes, to the fullest extent permitted by law, all liability for any loss or damage suffered by me in connection with the creation or use of the information I provided and/or will provide to Medtronic.
• I am granting Medtronic the rights described in this Consent Form in consideration of demonstrating to others the benefit I have received from a Medtronic product or therapy.
• I understand that I will have no further claim against Medtronic or any of its assignees in relations to any use of the materials that is in accordance with the terms of this Consent form.

I agree to the following:

Further information about how Medtronic and its affiliates will treat your personal data, as well as on your rights as data subject:

• I understand that my personal data may be transferred to other Medtronic companies that may be located in countries outside the European Economic Area (EEA) and Switzerland that may not have similar data protection laws. In that case, Medtronic will take all steps reasonably necessary to ensure that my data is treated securely and in accordance with this informed consent statement and the principles of the European data protection laws.
• Medtronic may use a third-party service provider who carries out services for or on behalf of Medtronic, such as technical services. In such case, my personal data will be transferred to such providers upon agreement to treat it in accordance with the aforementioned standards and to use it exclusively for the same purposes.
• I understand that I can obtain access to my personal data stored by Medtronic, ask for its correction and revoke the consents given above at any time by sending a written request to Medtronic by registered mail to this address 3555 Koger Blvd Suite 200 Duluth, GA, 30096 USA. As soon as possible after receiving a consent revocation, Medtronic will cease using the data in any new materials or media.

If your story is selected to share with others, we may contact you for additional information.