Curonix Digital Patient Education Kit Request Form

Curonix Digital Patient Education Kit Request Form

The Curonix Digital Patient Education Kit (defined more fully below) is intended for physician customers, practices, or other health care providers interested in obtaining patient education materials and content about the Curonix Freedom® Peripheral Nerve and Spinal Cord Stimulator Systems to provide education and awareness to patients in their local area.

The Curonix Digital Patient Education Kit includes: approved company and product information, product images, videos, and social media posts.

To submit a request for a Curonix Digital Patient Education Kit, fill out the form below to provide, the required information, read the terms of use and limited license below, and check off the box indicating you have read the terms of use. Your request will be sent to the Curonix Marketing Communications team for consideration.

*No Curonix Employee, Distributor, or Sales Representative is allowed to complete this request form.

Today's Date*

Required Information

Physcian Name*

Physician Title*

Medical License Number*

NPI Number*

Facility/Practice Name*

Also referred herein to as “you” or “your"

Facility/Practice Legal Entity Name (name on W-9) *

Street*

City*

State*

Select or enter value

Zip Code*

Email Address*

Telephone*

Phone

Identify the person authorized to make this request and agree to the terms of use on your behalf

FIrst and Last Name*

Position*

Select or enter value

Other:

Terms of Use and Limited License

Curonix LLC hereby authorizes and grants you non-exclusive, revocable, non-transferrable and limited license to access via the internet, use and display any portion of the certain images, videos, and content which shall be herein referred to as the “Curonix Digital Patient Education Kit” that Curonix shall make available for patient educational purposes free of charge. Your use of the Curonix Digital Patient Education Kit and the individual materials provided therein is approved for and shall be solely for the purposes of your own knowledge and to provide useful and accurate patient education to your patients. You shall not use any part of the Curonix Digital Patient Education Kit to promote products of any other company or to promote Curonix’s products for any unapproved uses, or in any way that is disparaging to Curonix or its products. Any use of the Curonix Digital Patient Education Kit for purposes other than stated above, without the prior written consent of Curonix, is strictly prohibited.

Curonix may terminate this license in whole or in part at any time for any reason, including by removing any Curonix images and/or videos you are accessing via the Internet without notice to you. In the event you are provided the Curonix Digital Patient Education Kit that you access via the Internet, and such Curonix Digital Patient Education Kit is modified in any way relative to any Curonix Digital Patient Education Kit you had previously accessed, this license shall continue to apply to the Curonix Digital Patient Education Kit as so modified (hereinafter referred to as a “New Kit”). In the event your license is revoked in whole, you should immediately cease using any part of the Curonix Digital Patient Education Kit.

The use or display of the Curonix Digital Patient Education Kit does not create, alter, or modify any agreement you may currently have, or had in the past, with Curonix. You agree that all materials contained in the Curonix Digital Patient Education Kit are exclusively owned by Curonix. You shall not modify any materials in the Curonix Digital Patient Education Kit, except with respect to any template documents provided for therein which indicate modification is necessary.

The contents included in the Curonix Digital Patient Education Kit are not intended as or a substitute for any medical advice.

The provision of the Curonix Digital Patient Education Kit does not constitute an offer of or solicitation for the purchase of Curonix products. Curonix is not granting any express or implied rights to you under any patents, trademarks, copyrights or trade secret information.

Neither Curonix, nor any parties involved in the creation, production or delivery of the content of the Curonix Digital Patient Education Kit shall be liable for any damages, including without limitation, direct, incidental, consequential, indirect or punitive damages, arising out of access to, use of or the inability to access or use the Curonix Digital Patient Education Kit, or any errors or omissions in the content thereof. Neither Curonix, nor its officers, directors, employees, affiliates, or other representatives shall be held liable for damages arising out of or in connection with your use of the Curonix Digital Patient Education Kit. You agree to indemnify and hold harmless Curonix LLC, its officers, directors, employees, affiliates, or other representatives from any liability associated with your use of the Curonix Digital Patient Education Kit.

Agree to Terms*

Please check the box below to acknowledge your receipt and acceptance of these terms and conditions. For clarity, your agreement to these terms allows continued use of each modified Curonix Digital Patient Education Kit (i.e., each New Kit) indicates your continued agreement to the terms of use herein. Should you no longer wish to be bound to these terms of use, then you must cease use of the Curonix Digital Patient Education Kit.

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