MERIT MEDICAL SYSTEMS, INC.

CONSENT TO PARTICIPATE IN PHYSICIAN REFERRAL PROGRAM

Merit Medical Systems, Inc. (“Merit”) provides a physician referral program (the “Physician Referral Program”) for individuals interested in contacting physicians to learn more about uterine fibroid embolization. Your participation in such program is entirely voluntary. Please read and review the Terms and Conditions of the Physician Referral Program before determining if you would like to participate. If you wish to participate in Merit’s Physician Referral Program please provide the information requested below and click the 'submit' button.

YOUR INFORMATION

You represent and warrant that all information you provide is true and correct. All questions with an '*' must be answered for you to be eligible to participate in the Referral Program.

NAME*

ADDRESS*

E-MAIL*

PHONE NUMBER

MEDICAL INSTITUTION*

MEDICAL INSTITUTION WEBSITE

ARE YOU A MEDICAL DOCTOR WITH AN ACTIVE LICENSE IN GOOD STANDING?*

DO YOU PROVIDE UTERINE FIBROID EMBOLIZATION?

TERMS AND CONDITIONS

These Terms and Conditions govern Merit’s Physician Referral Program. Merit may change these Terms and Conditions at any time in its sole discretion. By participating in Merit’s Physician Referral Program you agree to be bound by these Terms and Conditions and represent that all the information you have provided is true and accurate.

  • You acknowledge and agree that Merit may provide any information you submit or provide to users of Merit’s Physician Referral Program. Merit may provide your information by any manner, including by phone, email, letter, and through Merit’s websites.
  • Merit is not obligated to include you or any part of your submission in Merit’s Physician Referral Program.
  • Merit may remove you or any information you provide from Merit’s Physician Referral Program at any time in its sole discretion.
  • Merit may discontinue the Physician Referral Program at any time.
  • You may stop participating in the Physician Referral Program at any time by contacting the webmaster of this website and making such request in writing.
  • Any information you provide as part of your submission or participation in Merit’s Physician Referral Program is not confidential. Such information may be provided to users of the program and may be used by Merit for any purpose.

By clicking ‘submit’ you are confirming that you would like to participate in Merit’s Physician Referral Program and that you agree to all the Terms and Conditions of such Program.