Axonics^® Patient Ambassador Request Terms

Program Description: The Axonics Patient Ambassador Program connects prospective patients with individuals who have been implanted with an Axonics medical device. Patient Ambassadors are not employees of Axonics, and they do not provide medical advice. Please keep in mind that individual results will vary, so talk with your doctor to determine whether Axonics Therapy is right for you.

Authorization and Terms of Use: By submitting your request, you acknowledge and agree to the following:

• I am voluntarily sharing my personal information, including health information, with Axonics for the purpose of connecting with an Axonics Patient Ambassador.
• By submitting my request, I authorize Axonics to contact me by phone, email, or text message, and I understand that airtime, message, and data rates may apply.
• I am eighteen (18) years of age or older.
• I am interested in learning more about the Axonics medical device.
• I authorize Axonics to share the personal information that I disclose, including health information, with third-party Patient Ambassadors.
• I authorize Axonics to contact me to request additional information.
• I understand that the Patient Ambassador program does not offer medical advice or product technical support and will not replace conversations with my doctor.

If you have any questions about the Program, please contact Axonics at 1-877-9-AXONICS or by email at This email address is being protected from spambots. You need JavaScript enabled to view it. .