Clear_RetainerRing

CUSTOMER CONTACT REQUEST FORM

Please complete the following information and a 24-Hour Technical Support representative will contact you to process your request.

Option	Explanation
Request a replacement pump and return my pump with clear retainer ring upon receipt of replacement product	I want to receive replacement for my clear retainer ring pump when available and will return my clear retainer ring pump upon receipt of replacement product. IMPORTANT: Medtronic recommends consulting with your healthcare provider regarding the best option for you considering the safety considerations.
I do not need replacement pump and will return my pump with clear retainer ring	I already have been issued a replacement pump with a black retainer ring or no longer use my pump with a clear retainer ring, but still have the clear retainer ring pump in my possession, which I will return to Medtronic.
I do not want to replace or return my pump with clear retainer ring	I do not want to replace my clear retainer ring pump and will not return my clear retainer ring pump to Medtronic at this time. IMPORTANT: Medtronic strongly recommends replacing the clear retainer ring pump. Before choosing this option, Medtronic recommends consulting with your healthcare professional.

Please select one of the options below: *

Pump User First Name*

Pump User Last Name*

Email Address*

Call Back Phone Number*

Pump User Date of Birth*

Serial Number** (7 Characters) Numbers only*

Is your Pump Under Warranty?*

Select "NA" If you do not have clear ring

Is the pump retainer ring damaged?*

Select "NA" If you do not have clear ring

Is the reservoir able to lock into place in the pump?*

Select "NA" If you do not have clear ring

Street Address*

State*

Postal Code*