Enroll in Connections
To enroll in the Connections program and receive more information on VNS Therapy for the treatment of chronic or recurrent depression , please fill out the information listed below in as much detail as possible. This will help us send you the materials that would best suit your needs.

If you do not live in the United States, please go to our International website for more information.

If you have already enrolled in the Connections Program and would like a copy of the Portraits of Hope, please call a Cyberonics' Case Manager at 877-NOW-4VNS.

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First Name: *
Last Name: *
Street Address: *
Street Address 2:
City: *
State/Province: *
ZIP/Postal Code: *
Country: *
Home Phone: *
Fax:
Email: *

How did you find out about the VNS Therapy Web site?
(Required)

Pharmacy Newsletter
WebMD
Friend or Family Member
Internet Search
Newspaper or Magazine
Patient Conference Call
Psychiatrist
Radio
Support Group
Therapist
TV
VNS Therapy Patient

Are you a patient or friend/family member? (Required)

Patient
Friend/Family Member

Friend/Family Enrollment Form

When was your friend or family member diagnosed with depression?

Less than 5 years ago
5-10 years
11-20 years
More than 20 years
Don't know

How many different medications has your friend or family member ever taken for depression?

1 drug
2 drugs
3 drugs
4 drugs
5 drugs
6 or more drugs
Don't know

On a scale of 1 to 5, with 1 being “not very severe” and 5 being “very severe,” how would you rate your friend or family member’s current level of depression?

1
2
3
4
5

Having depression has severely restricted their life.

Agree strongly
Agree somewhat
Disagree somewhat
Disagree strongly

They feel like they’ve tried just about everything to treat their depression and there is nothing that works.

Agree strongly
Agree somewhat
Disagree somewhat
Disagree strongly

On a scale of 1 to 5, with 1 being “not very satisfied” and 5 being “very satisfied,” how would you rate your friend or family member’s current level of satisfaction with his or her current antidepressant treatment regimen?

1
2
3
4
5

Has a psychiatrist ever recommended that your friend or family member consider VNS Therapy as a potential long-term treatment option for your depression?

Yes
No

They rely solely on their psychiatrist’s recommendations.

Agree strongly
Agree somewhat
Disagree somewhat
Disagree strongly

They would rather have their psychiatrist make the decisions about what is best for them rather than have their psychiatrist give them a lot of choices.

Agree strongly
Agree somewhat
Disagree somewhat
Disagree strongly

They ask their psychiatrist about treatments they see advertised on TV.

Agree strongly
Agree somewhat
Disagree somewhat
Disagree strongly

Some depression actually resist treatment.If their depression has not completely responded to 4 or more treatments, or if their depression comes back over time, they may be experiencing Treatment-Resistant Depression.

From the list of statements below, please select the statement you feel best describes how the previous description applies to your friend or family member.

Patient Enrollment Form

When were you first diagnosed with depression?

Less than 5 years ago
5-10 years
11-20 years
More than 20 years
Don't know

How many different medications have you ever taken for your depression?

1 drug
2 drugs
3 drugs
4 drugs
5 drugs
6 or more drugs
Don't know

On a scale of 1 to 5, with 1 being "not very severe" and 5 being "very severe," how would you rate your current level of depression?

1
2
3
4
5

Having depression has severely restricted my life.

Agree strongly
Agree somewhat
Disagree somewhat
Disagree strongly

I feel like I’ve tried just about everything to treat my depression and there is nothing that works.

Agree strongly
Agree somewhat
Disagree somewhat
Disagree strongly

On a scale of 1 to 5, with 1 being "not very satisfied" and 5 being "very satisfied," how would you rate your current level of satisfaction with your current antidepressant treatment regimen?

1
2
3
4
5

Has your psychiatrist ever recommended that you consider VNS Therapy as a potential long-term treatment option for your depression?

Yes
No
Don't Know

I rely solely on my psychiatrist’s recommendations.

Agree strongly
Agree somewhat
Disagree somewhat
Disagree strongly

I’d rather have my psychiatrist make the decisions about what is best for me rather than have him/her give me a lot of choices.

Agree strongly
Agree somewhat
Disagree somewhat
Disagree strongly

I ask my psychiatrist about treatments I see advertised on TV.

Agree strongly
Agree somewhat
Disagree somewhat
Disagree strongly

Some depression actually resist treatment.  If your depression has not completely responded to 4 or more treatments, or if your depression comes back over time, you may be experiencing Treatment-Resistant Depression.

From the list of statements below, please select the statement you feel best describes how the previous description applies to you.

Definitely applies to me, because I've tried at least 4 anti-depressant treatments and still don't feel completely well.
Somewhat applies to me, because I've tried 2-3 anti-depressant treatments and still don't feel completely well.
Not sure if this applies to me, because I've only just begun taking anti-depressant treatment.
Does not apply to me, because although I've taken a number of medications, I feel OK now.

Terms and conditions
By submitting this information, you agree to the Cyberonics Terms and Conditions for use of this information. Please fill out the information listed above to the best of your knowledge. You do not need to answer all the questions to enroll in the Connections program.

   
 
   
 
       
  UNITED STATES INDICATION FOR USE:
The VNS Therapy System is indicated for use as an adjunctive therapy in reducing the frequency of seizures in adults and adolescents over 12 years of age with partial onset seizures, which are refractory to antiepileptic medications.

VNS Therapy (or the VNS Therapy System) is indicated for the adjunctive long-term treatment of chronic or recurrent depression for patients over the age of 18 who are experiencing a major depressive episode and have not had an adequate response to four or more adequate antidepressant treatments.