Case submission form

Share how you’ve used EMBOLD™ Detachable Coil System to help your patients.

Physician first name

Physician last name

Submitted on behalf of physician by (first and last name)

If you are submitting the case on behalf of someone else, please include your first and last name.

Hospital/Clinic

Patient presentation

Please do not provide any patient identifiable information or information that you are not appropriately authorized to share.

Intervention used

Outcome

Upload "before" image

Please upload a png or jpg image.

Upload "after" image

Please upload a png or jpg image.

By submitting this form, I consent to Boston Scientific using and sharing all information and images provided above on Boston Scientific approved social media channels and websites and for additional purposes outlined in the Boston Scientific Privacy Policy. I have read and agree to the privacy policy and terms of use.

* required