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 have a pump with clear retainer ring	I do not have the clear retainer ring pump in my possession.
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 (DD/MM/YYYY)*		Serial Number** (7 Characters) Numbers only*

Is your Pump Under Warranty?*

Is the pump retainer ring damaged?*

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

Street Address*

Postal Code*

State*

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