Send Us Your Story for the Victory Gallery

1. First name (required)
2. Last name (required)
3. What is your age? * Please select Under 18 18 - 24 25 - 34 35 - 49 50 - 64 65 - 75 75 +
4. Street address 1 (required)
5. Street address 2
6. City (required)
7. State * Please select AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NV NH NJ NM NY NC ND NE OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
8. ZIP/Postal Code (required)
9. Email address (required)
10. Phone number (required)

Depending on the content of your story, Medtronic may need to contact you or your physician. Please indicate the name of your neurologist as well as the city and state where his/her practice resides.

1. Neurologist name (required)
2. City/State (required)
3. What is the name of your local Medtronic representative?

Tell us your story

1. What helped you decide to pursue Medtronic DBS Therapy? (required)
2. What Daily Victories have you achieved since receiving Medtronic DBS Therapy? What is life like with DBS Therapy? How has your therapy impacted those around you? (required)
3. What has been most challenging in receiving Medtronic DBS
   Therapy? (required)
4. How has your neurologist (or other physician) helped with your DBS Therapy? (required)
5. What advice do you have for others who are considering Medtronic DBS Therapy? (required)
6. Upload supporting photos or video (optional)

By completing and submitting this form you are granting Medtronic permission to add your contact information to its database for deep brain stimulation and consent to receiving information and communications related to Medtronic products and therapies.

If you are submitting photography or video in which other individuals appear, you must mail us a signed release form from each individual featured.

By submitting materials to Medtronic, I hereby grant Medtronic an unrestricted, royalty-free, irrevocable license to use, reproduce, display, publish, edit, and distribute it, in whole or in part.

1. License * I agree.

If you are under 18 years of age and submitting a personal victory, you must provide your parent/guardian's first and last name and contact information so that we may obtain permission to use your story.

1. Parent/guardian name
2. Phone number
3. Email address

Please also remember that your submission is governed by our Terms of Use and Privacy.