Axonics Patient Ambassador Program Applicant Terms
The Axonics Patient Ambassador Program connects prospective patients with
individuals who have already been implanted with an Axonics medical device. The Patient Ambassador
Program provides each volunteer the opportunity to advocate on behalf of those suffering from
urinary or fecal dysfunction, answer questions, and share personal stories and experiences about
Axonics Therapy. Patient Ambassadors do not offer medical advice.
- I am voluntarily sharing my personal information, including health information, with Axonics for
the purposes of applying to be a volunteer (unpaid) Axonics Patient Ambassador.
- By enrolling in the Program, I authorize Axonics to contact me by phone, email, or text message,
and I understand that airtime, message, and data rates may apply.
- I understand that Patient Ambassadors are not Axonics employees.
- I am currently implanted with an Axonics medical device.
- I am eighteen (18) years of age or older.
- I understand that submitting an application does not guarantee that I will be selected to be a
- I understand that Axonics has sole discretion in selecting Patient Ambassadors.
- If I am selected by Axonics to be a Patient Ambassador, I understand that my participation is
conditioned upon the execution of an Axonics Patient Ambassador Participation Agreement.
- I authorize Axonics to contact me to request additional information or discuss my application.
- If I am selected by Axonics to become an Axonics Patient Ambassador, I understand that Axonics
will make my name and contact information available to Ambassador Program Members and will
publicize my position as an Ambassador through newsletters, social media, the Axonics website,
occasional mailings, and print brochures.
If you have any questions about the Ambassador Program, please contact Axonics at 1-877-9-AXONICS
or by email at This email address is being protected from spambots.