Intrathecal Baclofen Therapy

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Thank you for your interest in Medtronic ITB TherapySM (Intrathecal Baclofen Therapy). To help us provide you with the most appropriate resources, please take a moment to complete the questionnaire below.

Fields marked with * are required.

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1. * The approximate number of spasticity patients in my practice is:
  0
  1 - 10
  11 - 50
  51 - 100
  101 - 200
  201 - 400
  > 400
     
2. * My patient population is primarily:
  Adults (18+)
  Pediatric (Under 18)
  Both
     
3. * I treat the following indications (Please select all that apply):
  Brain Injury
  Cerebral Palsy
  Multiple Sclerosis
  Spinal Cord Injury
  Stroke
  Other
     
4. * Other than oral medications, I currently recommend the following treatments for spasticity (Please select all that apply):
  Injection Therapy (botulinum toxin or other)
  Orthopedic Surgery
  PT/OT
  ITB Therapy
  Selective Dorsal Rhizotomy
  Other
     
5. If you indicated above that you currently recommend ITB Therapy, please check the box below that best describes your experience level with the therapy (If you do not currently recommend ITB Therapy, please skip to question 7):
  1-5 patients annually
  6-10 patients annually
  11 + patients annually
     
6. Please describe your role with ITB Therapy (Please select all that apply):
  I refer the patient to another physician/clinician for an evaluation for ITB Therapy.
  I participate in the patient evaluation and make the decision regarding whether a patient should be screened for ITB Therapy.
  I evaluate the patient during the ITB Therapy screening test and determine whether or not the patient had a successful response.
  I perform the surgical implant of the pump and catheter.
  I manage the patient long-term after the pump implant (ongoing evaluation, dose management).
  I am just beginning to learn about ITB Therapy.
     
7. * I am interested in (Please check all that apply):
  A briefing by a Medtronic representative.
  Receiving updates from Medtronic such as clinical articles, educational opportunities, information on new products, etc.
     

By completing and submitting this form, you are granting Medtronic permission to add your contact information to its database for severe spasticity. You may revoke this permission at any time by sending a request to itbtherapy@medtroniceducation.com or Medtronic ITB Therapy Marketing, 710 Medtronic Parkway LN275, Minneapolis, MN 55432.