{"id":22080,"date":"2025-11-10T15:44:22","date_gmt":"2025-11-10T23:44:22","guid":{"rendered":"https:\/\/mainstaymedical.com\/?page_id=22080"},"modified":"2025-12-19T01:15:57","modified_gmt":"2025-12-19T09:15:57","slug":"patient-consent","status":"publish","type":"page","link":"https:\/\/mainstaymedical.com\/de\/patient-consent\/","title":{"rendered":"Patientconsent"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"22080\" class=\"elementor elementor-22080 elementor-16949\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-73ab731 e-flex e-con-boxed e-con e-parent\" data-id=\"73ab731\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-9093add elementor-widget-tablet__width-inherit elementor-widget__width-initial elementor-widget-mobile__width-inherit elementor-headline--style-highlight elementor-widget elementor-widget-animated-headline\" data-id=\"9093add\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;highlighted_text&quot;:&quot;das Patientenmarketing&quot;,&quot;headline_style&quot;:&quot;highlight&quot;,&quot;marker&quot;:&quot;circle&quot;,&quot;loop&quot;:&quot;yes&quot;,&quot;highlight_animation_duration&quot;:1200,&quot;highlight_iteration_delay&quot;:8000}\" data-widget_type=\"animated-headline.default\">\n\t\t\t\t\t\t\t<h1 class=\"elementor-headline\">\n\t\t\t\t\t<span class=\"elementor-headline-plain-text elementor-headline-text-wrapper\">Erm\u00e4chtigungsformular f\u00fcr<\/span>\n\t\t\t\t<span class=\"elementor-headline-dynamic-wrapper elementor-headline-text-wrapper\">\n\t\t\t\t\t<span class=\"elementor-headline-dynamic-text elementor-headline-text-active\">das 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var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_9' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Patient Marketing Authorization Form<\/h2>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>\u201e<span class=\"gfield_required gfield_required_asterisk\">*<\/span>\u201c zeigt erforderliche Felder an<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_9' id='gform_9' class='patient-auth' action='\/de\/wp-json\/wp\/v2\/pages\/22080#gf_9' data-formid='9' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_9_3\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p> By completing this Patient Authorization Form (<b>\u201cAuthorization\u201d<\/b>), you are giving permission to Mainstay Medical Limited, including its employees, agents, or representatives (<b>\u201cMainstay\u201d<\/b>) and\/or your health care provider (<b>\u201cProvider\u201d<\/b>), to utilize or share your personally identifiable data and content regarding your experiences and progress with the ReActiv8\u00ae Neurostimulation System (<b>\u201cReActiv8\u201d<\/b>) through videos, photographs, and\/or written statements (<b>\u201cRecorded Content\u201d<\/b>). The Recorded Content will include your likeness, image, and\/or voice, and will be recorded by Mainstay through a contracted agency or possibly with a Mainstay representative\u2019s smartphone. <u>Please only select the authorizations (by inserting checkmarks or your initials in the boxes) you agree to, and do not hesitate to contact your Mainstay representative with any questions.<\/u> <\/p><\/div><fieldset id=\"field_9_22\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >1) Updates to Your Physician \/ Health Care Provider (\u201cProvider\u201d)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_9_22'><div class='gchoice gchoice_9_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value='true'  id='choice_9_22_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_22_1' id='label_9_22_1' class='gform-field-label gform-field-label--type-inline'>By checking this box, you authorize Mainstay to share your Recorded Content with your Provider for purposes of informing them about your ReActiv8 progress, feedback, and updates. This can help your Provider better understand and manage your ReActiv8 therapy and your overall care. Please note that the Recorded Content may be sent to your Provider via upload to a secure site accessible by your Provider, or through a Mainstay smartphone\u2019s email or texting app (which may not utilize encryption or similar security measures).<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_23\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >2) Use of Recorded Content by Your Provider<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_9_23'><div class='gchoice gchoice_9_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='true'  id='choice_9_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_23_1' id='label_9_23_1' class='gform-field-label gform-field-label--type-inline'>By checking this box, you authorize your Provider to share or publicize your Recorded Content through the Provider\u2019s website, social media accounts (such as LinkedIn or Facebook), or other educational\/marketing platforms whether electronic or hardcopy. Among other things, your Recorded Content may be used to educate the public about ReActiv8 therapy, including prospective patients and their family members, and represent your Provider as a certified ReActiv8 clinician. If you agree, please identify your Provider:<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_8'>Provider or Practice Name<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_9_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_9_24\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >3) Mainstay Marketing &amp; Educational Purposes<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_9_24'><div class='gchoice gchoice_9_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='true'  id='choice_9_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_24_1' id='label_9_24_1' class='gform-field-label gform-field-label--type-inline'>By checking this box, you authorize Mainstay to use your Recorded Content for product education, public awareness, marketing, training, and\/or related purposes in the US and internationally, to help inform the public, health care providers, and potential patients about ReActiv8. As examples, your Recorded Content may be used in publications, Mainstay website(s), articles, marketing materials, or educational materials. The Recorded Content will become the property of Mainstay and you agree to assign full copyright of all manifestations of the Recorded Content to Mainstay together with the right of reproduction.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_10\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Your Recorded Content will not be used in any inaccurate, inappropriate, or misleading manner. Mainstay will not sell your Recorded Content to any other party without your permission. You agree to only showcase or perform what you are physically comfortable with regarding body movements or activities in your Recorded Content, and release Mainstay from any liability or harm that may result from the Recorded Content. You understand that Mainstay is a medical device manufacturer and cannot review your Recorded Content for any clinical issues or concerns. Please contact your Provider with any questions, issues or concerns (and, of course, call 911 in case of any emergency situation).<\/p><\/div><div id=\"field_9_11\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><b>I have read the above and agree to this Authorization.<\/b> This Authorization will be effective for a period of five (5) years, although you may rescind this Authorization at any time by providing Mainstay with written notice. You understand that you will not receive any compensation for this Authorization. Your agreement to share Recorded Content is completely voluntary, and you may refuse to sign this Authorization without any penalty or negative impact to your health benefits or ReActiv8 therapy. <\/p><\/div><div id=\"field_9_17\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_17'>Implant Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_17' id='input_9_17' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_9_17_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_9_17_date_format' class='screen-reader-text'>MM Schr\u00e4gstrich TT Schr\u00e4gstrich JJJJ<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_9_17' class='gform_hidden' value='https:\/\/mainstaymedical.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_9_18\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_18'>Implant Type<\/label><div class='ginput_container ginput_container_select'><select name='input_18' id='input_9_18' class='large gfield_select'     aria-invalid=\"false\" ><option value='Commercial' >Commercial<\/option><option value='Clinical Trial' >Clinical Trial<\/option><\/select><\/div><\/div><div id=\"field_9_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_19'>Country<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_9_19' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_21\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_21'>State\/Region<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_9_21' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_20\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_20'>City<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_9_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_13\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_13'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_13' id='input_9_13' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_9_13_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_9_13_date_format' class='screen-reader-text'>MM Schr\u00e4gstrich TT Schr\u00e4gstrich JJJJ<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_9_13' class='gform_hidden' value='https:\/\/mainstaymedical.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_9_12\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_12'>Signature<span class=\"gfield_required\"><span class=\"gfield_required 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