Axonics^® Ambassadors

Become an Axonics Patient Ambassador

Do you remember when you thought you had no options or didn’t know how to express the daily challenges you faced with your urinary or bowel dysfunction?

Imagine what it would’ve been like to talk to someone who had experienced the same exact symptoms as yours.

As a Patient Ambassador, you will provide a voice for patients who believe there is no one listening.

If you’re selected as a Patient Ambassador volunteer, you will have the unique opportunity to share your real-life story with other patients, caregivers, and medical professionals. You will raise awareness of a life-limiting condition that affects millions of people like you and their caregivers.

Why not tell people about your success using the Axonics System? Fill out the Patient Ambassador application and you could make a difference!

Take The Quiz. Find A Specialist.

Do you experience any of the following bowel and/or bladder control symptoms?
(Choose all that apply) Frequent urination Sudden or strong urge to urinate Urine leakage with little or no warning Urine leakage with exertion (eg, laughing, sneezing, exercise) Incomplete emptying of the bladder Bowel Leakage None of the above

How long have you had bladder control symptoms? Less than 6 months 6 to 12 months Between 1 and 5 years More than 5 years

How much do your bladder control symptoms affect your quality of life? Very severely Severely Moderately Slightly No effect

Has a doctor ever diagnosed you with any of the following?
(Choose all that apply) Overactive bladder (OAB) Urge urinary incontinence (UUI) Stress urinary incontinence (SUI) Urinary retention (UR) Fecal incontinence (FI) None of the above

Do you currently have a doctor managing your bladder control issues?
(If you have several, choose the one you consult most often.) Primary care doctor OB/GYN Urologist Urogynecologist Another doctor I don't have a doctor at this time

Have you ever tried any of the following treatments?
(Choose all that apply) Lifestyle changes (eg, dietary changes, limiting or timing fluid intake) Pelvic floor exercises or pelvic physical therapy Sacral neuromodulation (SNM, eg, Axonics or InterStim) Pelvic sling or other surgical procedure BOTOX injections None of the above

How old are you? 17 or younger 18 to 34 35 to 49 50 to 64 65 to 79 80 or older

What is your sex, as assigned at birth? Male Female I prefer not to say

What type of insurance do you have? Private insurance (either employer-provided or self-purchased) Medicare or Medicare Advantage Medicaid or government-assisted program TriCare/Veterans Affairs No insurance/self-pay

Are you currently taking prescription bladder control medication(s)? Yes No, but I have tried them in the past No, I’ve never taken them

How many prescription bladder control medications have you tried? One Two Three or more None of the above

Why did you stop taking your bladder control medication?
(Choose all that apply) Never worked Did not work well enough Stopped working Side effects Cost/insurance issues Other None of the above

How did you hear about us?
(Choose all that apply) TV ad Internet - Facebook/Instagram Internet - Web Search/Browsing Doctor recommendation Family member/friend YouTube Other

When is a good time for us to call you with more information about physician providers in your area?
(Choose all that apply) Right now (weekday business hours only) Morning (8 – 11am) Midday (11 – 2pm) Afternoon (2 – 5pm) No preference

You're almost done! Share your contact details to see if you qualify First Name: Last Name: Email: Phone: Zip Code: By clicking “See if I qualify” and submitting this form (the “Quiz”), I agree that Axonics, Inc. (“Axonics”), their agents, representatives, affiliates, or anyone calling on their behalf, may use the information collected in the Quiz to contact me about Axonics products and services, including through electronic messages, prerecorded, artificial, or voice calls and messages delivered using automatic telephone dialing systems, and to share the information I provide in this form with health care providers who may be in my area. I affirm that I am at least 18 years of age. I can opt-out at any time by contacting marketing@axonics.com. For more about how we protect information and privacy rights which may apply, please see our privacy policy at www.axonics.com/privacy.
By checking this box, I expressly consent to receiving text messages, including through an automatic texting system, regarding Axonics products and services at the phone number provided above. Message and data rates may apply. I will be able to opt-out at any time by responding with “STOP” to any text message received from Axonics.
For more information about safety and potential risks, go to www.axonics.com/isi.

Axonics® Privacy Policy

Axonics, Inc. has created this Privacy Policy to document and demonstrate our firm commitment to privacy. This Privacy Policy describes the ways in which Axonics and its affiliates, service providers, and subsidiaries (collectively, “Axonics,” “we,” “our,” or “us”) may collect, use, and disclose personal information obtained or gathered through the use of Axonics websites or services that link to this policy (the “Services”). By using the Services and/or disclosing personal information, you consent to the processing of your personal information as set forth in this Privacy Policy, which is incorporated into our Terms of Use. This Privacy Statement is intended for website users in the United States. We will not sell the personal information that you provide to us.

What Information Do We Collect?

There are various places on the Axonics website where you can elect or sign-up to receive information from Axonics. We may collect the following categories of personal information about you in connection with your use of the Services:

Information You Provide: We and our Service providers collect personal information that you may voluntarily share when you use the Services, including, but not limited to, information about your:

Contact information, such as your first name, last name, email address, address, phone number;
Demographic information, including your age, birth date, and gender;
Professional information, including your employment status, employer information, title, occupation, and professional affiliations;
Account information, including your username and password;
Health information, including your health status, diagnoses, treatments, and symptoms;

Information Automatically Collected From You: We and our service providers may automatically collect certain information about you and your online activities when you use the Services. We may collect personal and non-personal information, including, but not limited to, your Internet Protocol address, general geographic location, browser type, operating system, the pages you view on the Services, the pages you view immediately before and after you access the Services, links you follow on our website, and the search terms you enter on the Services.

How Do We Use Your Information?

We may use the information we collect for a number of purposes, including:

to provide you with products, services, or information you request;
to provide you with information about the Services or required notices;
to deliver marketing communications, promotional materials, or advertisements that may be of interest to you;
to customize your experience when using the Services, such as by providing interactive or personalized elements on the Services and providing you with content based on your interests;
to improve the Services, such as by better tailoring our content to our users’ needs and preferences;
to generate and analyze statistics about your use of the Services;
to answer your questions about the Services, or otherwise communicate with you about the Services;
for our business purposes, such as monitoring and prevention of fraud, intellectual property infringement, violations of our Terms of Use, violations of law, or other potential misuse of the Services.

When and to Whom Do We Disclose Your Information?

The information that we collect from and about you may be used internally by Axonics and may also be disclosed:

to third parties that provide services to us in connection with our business operations and that have agreed to keep the information confidential;
to business partners who offer products or services jointly with us or with our subsidiaries or affiliates;
as required by law, such as to comply with a subpoena or other legal process, or to comply with government reporting obligations;
when we believe in good faith that disclosure is necessary (a) to protect our rights, the integrity of the Services, or your safety or the safety of others, or (b) to detect, prevent, or respond to fraud, intellectual property infringement, violations of our Terms of Use, violations of law, or other misuse of the Services; and
to service providers, advisors, potential transactional partners, or other third parties in connection with the consideration, negotiation, or completion of a corporate transaction in which we are acquired by or merged with another company or we sell, liquidate, or transfer all or a portion of our assets.

Use of Cookies

To enable us to provide customized and personalized services, we and our service providers use cookies and similar tools to store and sometimes track information about you. A cookie is a small amount of data that is sent to your browser from a Web server and stored on your computer. If you do not want the Services to collect information through the use of cookies, you can set your web browser to reject cookies. Each browser is different, so you should check your browser’s “Help” menu to learn how to change your cookie preferences. If you reject or block cookies from the Services, however, the Services may not function as intended.

Use of Google Analytics

Google Analytics uses cookies to track your interactions with our website and online Services. Google then collects that information and reports it back to us. For more information on Google Analytics, visit “HOW GOOGLE USES INFORMATION FROM SITES OR APPS THAT USE OUR SERVICES” located at: https://www.google.com/policies/privacy/partners/.

Do Not Track Signals

California law requires that we share how we respond to website browser “do not track” signals. We do not currently recognize or honor “do not track” signals or other mechanisms that provide a method to opt out of the collection of information across websites or other online services. If we do so in the future, we will describe how we do so in this Privacy Policy. Visit the following website, www.allaboutdnt.org, for more information.

Your California Privacy Rights

If you reside in California and have provided your personally identifiable information to us, you may request information once per calendar year about our disclosures of certain categories of your personally identifiable information to third parties for their direct marketing purposes. Such requests must be submitted to us in writing at This email address is being protected from spambots. You need JavaScript enabled to view it..

Children's Information

The Services are not intended for or directed to individuals under the age of thirteen (13). If a parent or guardian becomes aware that his or her child has directly provided us with personal information, please contact us by using the contact information below.

Changes to This Privacy Policy

We may update this Privacy Policy from time to time. If we update this Privacy Policy, we will notify you by posting a new Privacy Policy to this page. If we make a material change to our Privacy Policy, we will take reasonable steps to notify you, for example by posting a banner on the Services website, prior to putting the changes into effect.

Contact Us

If you have any questions, please contact us at This email address is being protected from spambots. You need JavaScript enabled to view it..

Effective Date: July 8, 2019