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If you have a medical emergency or you need specific medical advice, you should contact your primary healthcare provider or your local emergency room.

This form is for customers in the Unites States only. For support outside the United States, see our list of international locations.

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Date the pump error occurred? MM/DD/YYYY

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Pump Serial Number (NG#######H)
Only enter 7-digit numbers

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I understand that the pump will arrive with factory settings and will require programming and following the pump rewind instructions to properly seat the reservoir prior to use.

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I agree to return the pump experiencing a critical pump error within 14 days of the replacement pump arrival.

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I agree to return the continuation of therapy loaner pump within 90 days of the loaner pump arrival.

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I understand that I may be charged a non-return fee of $3600 if I do not return the in warranty pump experiencing critical pump error or continuation of therapy loaner device to MiniMed within the allotted time.

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In relation to the Critical Pump Error you experienced, were you hospitalized, did you seek emergency medical assistance, or experience any other adverse events?

Yes I have No I have not

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Have you already reported the adverse events to our 24-Hour Technical Support team?

Yes No

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First name (of person with diabetes)

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Last name (of person with diabetes)

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Address

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City

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State

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ZIP

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Phone number

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Message

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This form is for customers in the Unites States only. For support outside the United States, see our list of international locations.

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Contact us via phone

1-800-646-4633 (toll-free)

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U.S. customers traveling internationally

+1-818-576-5555

Contact us via mail:

MiniMed Distribution Corp.
18000 Devonshire Street
Northridge, CA 91325
USA