I authorize my physician to
share with NeuroPace, Inc. (“Company”) information from the medical records my
physician is maintaining for me, including my protected health information
(e.g., medical history, diagnosis, and health insurance information) and
contact information (e.g., name, phone number, and email address), so that
NeuroPace can contact me with information, including educational information
about the RNS System, to help determine if the NeuroPace RNS System may be
right for me.