In order to register for the online InterStim® Physician Education Program, please fill out this form and click the "Request Access" button. Please follow the example for entering your registration information on the right, using caps and lowercase, as specified. How you enter your information, is how it will appear on your letter and certificate.
Fields marked with an asterisk (*) must be filled out in order for us to process your request.
    Example:
Title: MD
First Name:* John
Middle Name: T.
Last Name:* Smith
Facility/Institution:* Madison Urological Assoc.
Address:* 111 42nd Street
Building: Madison Medical Towers
Suite: Suite 209
City:*

 Madison
State/Province:
(Required, if US resident)

 WI
Zip/Postal Code:
(Required, if US resident)

 12345
Country:*
Other:
 
Phone Number:*  
Fax Number:  
E-mail Address:*  
Re-enter E-mail Address:*  
Medical Specialty:*
Other:
 

Please fill out these fields if you chose "Medtronic Employee" as your medical specialty:

Mail Stop Number: 
Employee Number: 
Extension: 
 
 
What is your interest toward this online course?*

I am interested in implanting InterStim
I am interested in referring patients to an implanting physician
I have attended an InterStim Therapy workshop and I would like to view the course as a refresher
I am interested in attending the InterStim Therapy online course for information only
 
 
How did you learn about this program?*
Other: