InPen™ Smart Insulin Pen

Replacement Request

Please complete the form below to request a replacement InPen™ smart insulin pen.

For more information, please read the InPen™ Smart Insulin Pen Cartridge Holder Assembly Issue

Actions required:

1. Locate the lot number for your InPen: You can find the lot number in two locations.

The first location is the fold-over label that is affixed to the InPen box/carton	The second location is on the dose knob portion of the InPen

2. Verify if your lot number matches one of the following impacted lot numbers:

D0020 D0021 D0026 D0027 D0028 D0029 D0030

D0031 D0032 D0033 D0034 D0035 D0036 D0037

D0038 D0039 D0040 D0041 D0042 D0043 D0044

D0045 D0046 D0047 D0048 D0049 D0050 D0051

D0057 D0059 D0060 D0061 D0062 D0068

Is your InPen lot number on the impacted list? *

Please select Yes No

Have you already started using the InPen from the impacted list? *

Please select Yes No

Have you experienced any issue with the cartridge? *

Please select Yes No

InPen user first name*

InPen user last name*

InPen user email address *

Phone number*

Alternative phone number

InPen user date of birth*

Lot number (enter 4 numbers that appear after D)*

D

Address* (Physical address required, no PO boxes)

City*

State*

Please select... Alaska Alabama Arkansas American Samoa Arizona California Colorado Connecticut D.C. Delaware Florida Micronesia Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri Marianas Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming Military Americas Military Europe/ME/Canada Military Pacific Alberta Manitoba British Columbia New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory

State*

ZIP code*

Country / Region

-- Please select -- Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil Brit/Indian Ocean Terr. BRITISH INDIAN OCEAN British Indian Ocean Ter British Indian Ocean Territory Brunei Brunei Darussalam Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Co´te D'Ivore Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Dem. Republic Of Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia European Union Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Terr. Gabon Gambia Georgia Germany Ghana Gibraltar Great Britain Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard/McDonald Isls. Honduras Hong Kong SAR Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea (North) Korea (South) Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar N. Mariana Isls. Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Norway Oman Pakistan Palau Palestine Palestinian Territory Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Martin Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Sao Tome/Principe Saudi Arabia Senegal Serbia Serbia and Montenegro Seychelles Sierra Leone Singapore Slovak Republic Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka St. Helena St. Pierre and Miquelon St. Vincent and Grenadines Sudan Suriname Svalbard/Jan Mayen Islands Svalbard/Jan Mayen Isls. Swaziland Sweden Switzerland Syria Taiwan Region Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks/Caicos Isls. Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay US Minor Outlying Is. USA Uzbekistan Vanuatu Vatican City Vatican City (Holy See) Venezuela Viet Nam Vietnam Virgin Islands (British) Virgin Islands (U.S.) Wallis/Futuna Isls. Western Sahara Yemen Zambia Zimbabwe

I understand that the replacement InPen™ request will be processed as inventory becomes available and that I will be notified via email when the InPen™ smart insulin pen has been shipped*

Your InPen is not affected by this issue, and you can continue to use your InPen as normal.

If you have already inserted your insulin cartridge into your InPen and are using your InPen successfully, then your InPen is not affected by this issue, and you can continue to use your InPen as normal.