NeuroPace, Inc

RNS System Patient Volunteer Agreement


I, , volunteer to share my experiences with the NeuroPace® RNS® System with patients and/or caregivers (“interested individuals”) who want to find out more about what it is like to be treated with the RNS® System, and NeuroPace, Inc. would like to help connect me with those interested individuals. This agreement documents the relationship between me and NeuroPace for accomplishing this purpose.

I agree that:

  • I will not receive compensation from NeuroPace for my work as a volunteer.
  • NeuroPace is free to save and share the contact information I provide on the Volunteer Information form to interested individuals who NeuroPace believes may find what I have to share helpful. If I decide that I no longer want to be a volunteer, NeuroPace will not share my information.
  • When I communicate with an interested individual, I will limit the information I provide to my own personal experiences with the RNS® System.
  • I will not recommend a specific surgeon or neurologist to an interested individual. If asked, I can refer them to the “Find an Epilepsy Center” section of NeuroPace’s website at neuropace.com or by going to the “Find a Doctor” section of the Epilepsy Foundation’s website at www.epilepsyfoundation. com.
  • I will respect the privacy of the interested individual. If I am provided with contact information for an interested individual, I will keep it confidential and not share it with anyone else or anywhere else (for example, my own website or otherwise on social media).

NeuroPace agrees that:

  • While NeuroPace will keep in its files your contact information and the other information you provide on the accompanying form, and will share it with individuals interested in hearing from you about the RNS® System, NeuroPace will not disclose your information publicly or to others without your permission, and NeuroPace will not sell or provide your information to a third party for marketing activities.

Other terms and conditions:

  • I will not represent to any person or entity that I am an employee of NeuroPace, or that I have the authority to contractually or otherwise bind NeuroPace. I will not make any claim or have any right or privilege available to a NeuroPace employee, including a salary or other compensation, worker’s compensation coverage, unemployment insurance benefits, or membership in any employee benefit, pension, or retirement plan to which NeuroPace is a party or contributes.
  • This agreement and the relationship can be terminated at any time, by me or by NeuroPace, immediately upon written notice. After termination, I agree to keep confidential the contact information of any interested parties and NeuroPace agrees to maintain the confidentiality of my information.
  • I hereby release and forever discharge and hold harmless NeuroPace, its successors and assigns, its employees, representatives, agents and directors from any and all injury, damage, claims, liability and demands of whatever kind or nature, either in law or equity, which arise or may hereafter arise from my volunteering under this agreement. I understand that this provision forever discharges NeuroPace from any liability or claim that I may have against it with respect to any bodily injury, illness, death, or property damage that may result from my efforts as a patient volunteer.
  • I agree that this agreement will be governed by the laws of the State of California.

BY SIGNING BELOW, YOU AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT:

MAILING ADDRESS:

PHONE:

EMAIL:

Signed by NeuroPace Inc.
Signed On: August 29, 2016

NeuroPace, Inc http://www.neuropace.com
Signature Certificate
Document name: RNS System Patient Volunteer Agreement
Unique Document ID: ebc06d9c0ac36708de78d9c7fc9bba8ef6aff720
Timestamp Audit
2016-08-24 09:55:44 PDTRNS System Patient Volunteer Agreement Uploaded by NeuroPace Inc. - connect@neuropace.com IP 173.228.54.97