Physician Locator Consent Letter
As we discussed with you, Mainstay Medical would like to provide patients and other parties who are interested in the ReActiv8 system with the full contact information of those health care providers who are trained and knowledgeable about the ReActiv8 system. If you consent to your practice’s inclusion in our database (as described below), our website visitors will be able to search for your practice as well as other ReActiv8-certified health care professionals depending on their geographic area. Please review the consent paragraph below for more details.
Consent – Provider Locator Database: I authorize Mainstay Medical to include my name, practice, and full contact information in their ReActiv8-certified provider database. I understand that my information will be included with other ReActiv8-certified health care providers in a HCP-locator service on Mainstay’s website. This will be provided as a courtesy and convenience for interested patients and other parties, who will be able to search for ReActiv8-certified providers in their geographic area. If interested patients contact Mainstay directly (e.g., through patient education, awareness, or similar marketing campaigns) and request information about certified practices, Mainstay may directly refer such patients to my practice depending on their geographic location. I understand that this invitation is open to all ReActiv8- certified providers, and Mainstay Medical cannot make any promises, guarantees, or assurances regarding who may contact my practice or their specific health care needs/interests. I also understand that, at any time, I can request Mainstay Medical to remove my contact information from the provider locator database, which shall be done promptly.
By providing my contact information and signing below, I consent to and authorize Mainstay Medical to include my contact information in its “provider locator database”, as described above.