First Name *

Last Name *

Suffix

Practice Name *

Email * For internal use only to send you a confirmation of registration. Email address will not be published on the surgeon finder.

Practice Address *

Practice Address 2

Practice City *

Practice State/Province *

Postal Code *

Practice Country *

Practice Phone Number *

Practice Website *

Practice Email Will be displayed on your profile in the Aquablation.com surgeon finder.

Bio *

Undergraduate Institution

Medical School *

Residency

Fellowship

Languages spoken

Confirmation of data protection * I consent to PROCEPT BioRobotics processing my personal data, which I provide via the contact form, for the purpose described above. I can withdraw my consent at any time with future effect by writing to: dataprivacy@procept-biorobotics.com.

Consent to use my submission * I hereby grant PROCEPT BioRobotics Corporation the right to use my submission, which may include my name, voice, likeness, biographical information, and personal/family story.

Comments

By entering information on our website, you understand and agree that your personal information may be processed, transferred, and/or stored in countries other than the country in which you reside, including the United States. These countries may have different data protection laws than the country in which you reside or work. Please do not submit any information you do not wish to have processed, transferred, and/or stored in the United States or any other country that is not the one in which you reside or work. In order to enable us to deal with your inquiry appropriately, and if applicable, for the monitoring of our device products' safety, we may share your data with health authorities as required by applicable laws as well as with our service providers. You have a right of access and correction of your personal data which we hold about you. The information you send through our websites will be governed by local regulations and PROCEPT BioRobotics's Privacy Policy.

PROCEPT BioRobotics offers a physician locater tool on its websites: PROCEPT-BioRobotics.com and aquablation.com. This consent form serves as written confirmation of your agreement to have your contact information (e.g., name, address, telephone number) listed on the website as a healthcare provider who performs Aquablation therapy. By completing this consent form, you acknowledge that the public will be able to locate your contact information based on a geographic search tool, and that you may be contacted regarding Aquablation therapy. You may rescind this consent at any time by sending an email to marketing@PROCEPT-BioRobotics.com. Your information will be removed from the website listing within 10 business days.

If you are a resident of the European Economic Area (EEA), you confirm you have also reviewed and understood the below supplemental notice for data subjects in the EEA. You affirm that you are at least 18 years of age and hereby grant your consent:

Supplemental notice for data subjects in the European Economic Area:

1. Categories of Personal Data: name, picture, photo, text, content, likeness and professional background
2. Purposes of Data Processing: promotion of PROCEPT BioRobotics's business, products and services
3. Recipients of Personal Data: public
4. Data Controller Details: PROCEPT BioRobotics Corporation, 900 Island Drive, Suite 210, Redwood Shores, California 94065, USA
5. Representative in the EEA:PROCEPT BioRobotics GmbH
6. Data protection officer: EEADataProtection@PROCEPT-BioRobotics.com
7. Legal Basis for Processing: Your consent and Art. 6(1)(a) GDPR
8. Recipients in Third Countries: PROCEPT BioRobotics is based in the United States, a country with respect to which the European Commission has not issued an unlimited adequacy decision. Your personal data will be accessible anywhere in the world if PROCEPT BioRobotics publishes it on its website
9. Period of Data Storage: PROCEPT BioRobotics will cease using your personal data seven years after the last PROCEPT BioRobotics system is sold, but once published on its website, your personal information will likely remain accessible indefinitely
10. Data Subject Rights: You have a right to request access to and rectification or erasure of your personal information, restriction of processing, data portability, withdrawal of your consent with effect for the future, and to lodge a complaint with a supervisory authority