VNS Therapy Patient Ambassador Program Application

If you would like to apply to be part of the Patient Ambassador Program, please complete this form. In the event an ambassador is needed in your area, we may contact you with further information. Before submitting your application, please be sure to read the Terms and Conditions below.

(* Required)

*	First name
*	Last name
*	Street address
*	City
*	State/Province
*	ZIP/Postal code
	Country
	Work phone
*	Home phone
	FAX
*	E-mail

Please answer the questions below to the best of your knowledge.

If you have VNS Therapy, answer for yourself
If you care for another person who has VNS Therapy, please provide answers that relate to his or her situation

How long have you or your loved one had seizures?
How many anti-seizure medications were being used at the time VNS Therapy was begun?
Have you or your loved one ever tried the ketogenic diet or brain surgery?	Yes No
On a scale of 1 to 5, with 1 being “not very satisfied” and 5 being “very satisfied,” how would you rate your level of satisfaction with the seizure treatment regimen before you or your loved one started VNS Therapy?
How long have you or your loved one had VNS Therapy?
How long after VNS Therapy was started did you begin to notice improvement?
On average, how many seizures do you or your loved one have in a month?
How many anti-seizure medications are you or your loved one currently taking?
How has quality of life changed for yourself or your loved one since VNS Therapy was started? (Check all that apply)	Able to go to school/work More independent Better daily functioning Better memory Better verbal skills Shorter postictal periods More energy Improved social interactions None of the above
How often do you talk to people about your VNS Therapy story?	Every week Every month A few times a year
Would you like to communicate with potential or newly implanted VNS Therapy patients?	Yes No
If yes, how?	By e-mail By phone In front of a group
Do you have any experience with public speaking?	Yes No
Are you a member of any support groups such as the Epilepsy Foundation?	Yes No

Terms and Conditions

Please fill out the form above to the best of your knowledge. Before submitting the completed application, please read the following Cyberonics Terms and Conditions for use of the information your application contains.

I hereby give my permission for Cyberonics, Inc., to use my name, phone number, and diagnosis information to contact me. I understand that I may revoke this authorization in writing at any time by sending a written notice to Cyberonics, Inc., at 100 Cyberonics Boulevard, Houston, TX 77058. Notice may also be faxed to Cyberonics at 281-218-9332. This authorization expires in 5 years unless earlier revoked. Cyberonics, Inc., will keep my information confidential, may not condition the sale of a device intended for my use on my completion of this authorization form, and will not receive compensation in exchange for contacting me.

Check here if you understand and agree to the Terms and Conditions.