AngioDynamics Travel Registration & Sunshine Act Form

Fill out the information below, then click Next to continue. 

Please fill out First, Middle, & Last name fields as it appears on your driver's license or passport for travel purposes.

 

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Hospital Type (Physician/Teaching):

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Primary Business Address:
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Would you like to join us for a casual gathering on Friday evening? 

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By submitting this Form, the undersigned attests to the following:

1.  All information provided in this Form is true and accurate to the best of my knowledge.

2. The undersigned, AngioDynamics, and their respective employees, sales representatives, representatives, or agents have not stated or implied, explicitly or implicitly, that the training course and travel and lodging being provided by AngioDynamics is intended to provide prohibitive remuneration or impose any requirements for the purchase, use, order, or recommendation of AngioDynamics’ products or services.

3. The undersigned agrees to comply with all applicable laws, rules, and regulations in connection with the product education course, including, without limitation, the AdvaMed Code and the Affordable Care Act, and any applicable reporting requirements.

4. The undersigned acknowledges that providing the information on this form is voluntary and that some of the information may be used by AngioDynamics to comply with applicable federal, state, or local laws, rules, regulations, and reporting requirements. AngioDynamics is required to report certain transfers of value to physicians and teaching hospitals, including, without limitation, the cost of travel, lodging, meals, and other expenses.