MiniMed^™ 600 Series Pump Retainer Ring

Recall Response Form

Please complete the information below to record your response to this important recall notification.
For more information, please visit the Product and Service Information Updates page.
If you have issues viewing or accessing the form on your mobile device, please use a computer.

Clear Retainer Ring Pump (Subject of Recall)	Black Retainer Ring Pump (Not Affected by Recall)
	Normal pump with black retainer ring

Option	Explanation
Request a replacement and return pump with clear retainer ring	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: *

-- Please Select -- Request a replacement and return pump with clear retainer ring I do not need a replacement pump and will return my pump with clear retainer ring I do not have a pump with a clear retainer ring I do not want to replace or return my pump with clear retainer ring

Pump User First Name*

Pump User Last Name*

Pump User Email Address *

Phone Number*

Alternative Phone Number

Pump User Date of Birth*

Serial Number (7 digits)* Enter the number only

NG

Example: NG 1 2 3 4 5 6 7  H

H

Where to find your serial number?
MiniMed™ 630G | MiniMed™ 670G | MiniMed™ 770G

Is the pump retainer ring damaged?*

-- Please Select -- Yes No I don't know

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

-- Please Select -- Yes No I don't know

We will be able to process your replacement request online. Please provide a shipping address that can be used for shipment as inventory becomes available. We will email you in the next few days about the status of your replacement order.

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

Zip Code*

Country / Region

-- Please Select --AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBrit/Indian Ocean Terr.BRITISH INDIAN OCEANBritish Indian Ocean TerBritish Indian Ocean TerritoryBruneiBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCo´te D'IvoreCocos (Keeling) IslandsColombiaComorosCongoCongo, The Dem. Republic OfCook IslandsCosta RicaCote d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaEuropean UnionFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern Terr.GabonGambiaGeorgiaGermanyGhanaGibraltarGreat BritainGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard/McDonald Isls.HondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea (North)Korea (South)KosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarN. Mariana Isls.NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorwayOmanPakistanPalauPalestinePalestinian TerritoryPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRussian FederationRwandaSaint Kitts and NevisSaint LuciaSaint MartinSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSao Tome/PrincipeSaudi ArabiaSenegalSerbiaSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovak RepublicSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth KoreaSouth SudanSpain Sri LankaSt. HelenaSt. Pierre and MiquelonSt. Vincent and GrenadinesSudanSurinameSvalbard/Jan Mayen IslandsSvalbard/Jan Mayen Isls.SwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks/Caicos Isls.TuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying Is.USAUzbekistanVanuatuVatican CityVatican City (Holy See)VenezuelaViet NamVietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis/Futuna Isls.Western SaharaYemenZambiaZimbabwe

I understand that the replacement pump will arrive with factory settings and will require programming before use*

I understand that the replacement pump will be processed as inventory becomes available and that I will be notified via email when the pump has been shipped*

I agree to return pump with clear retainer ring with the included return packaging when replacement device arrives*