Become an Axonics Patient Ambassador

First Name*

Last Name*

Zip Code *

State*

Select or enter value

Phone Number*

Email*

Are you a U.S Resident?

Select or enter value

Birth Date*

Gender*

Select

Are you a healthcare professional?*

Select

Occupation*

Condition*

Overactive bladder (including urgency incontinence, frequency and nocturia)

Bowel (fecal) incontinence

Urinary retention

Other

How old were you or the person you care for when this condition started affecting your life?*

Please briefly describe your history with this condition:*

When did you start on Axonics Therapy?*

Best estimate

Please select your level of agreement with each statement

How often do you post/share on the following social media channels?

Please share links to your social media channels

Note: this is required for review of your application

Facebook Link

Instagram Link

YouTube Link

LinkedIn Link

Personal Blog Link

Other

Approximately how many people living with urinary or bowel dysfunction do you directly communicate with ONLINE on a weekly basis?*

Less than 10

11-50

51-99

100+

Approximately how many people living with urinary or bowel dysfunction do you directly communicate with OFFLINE on a weekly basis?*

Less than 10

11-50

51-99

100+

How comfortable are you with someone reaching out to you via email about urinary or bowel dysfunction?

Very comfortable

Unsure

Uncomfortable

How comfortable are you with someone reaching out to you via phone about urinary or bowel dysfunction?

Very comfortable

Unsure

Uncomfortable

Please tell us why you would like to be a part of the Axonics Ambassador Program and what you hope to accomplish if accepted?*

By checking this box and submitting your information, you confirm that you have read and consent to Axonics' Privacy Policy and agree to the Patient Ambassador Program Applicant Terms.

Confirm*

Send me a copy of my responses