MiniMed™ Remote Controller

Return Request Form

Please complete the following information to initiate your MiniMed™ Remote Controller return request.
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.

Option	Explanation
Return remote controller	I want to return my affected remote controller and receive a prepaid return package.
I do not have either of the affected remote controllers	I do not have either of the remote controllers in my possession.
I do not want to return my remote controller	I do not want to return my remote controller to Medtronic at this time. IMPORTANT: Before choosing this option, Medtronic recommends consulting with your physician regarding safety considerations.

Please select one of the options below:*

Pump User First Name*

Pump User Last Name*

Pump User Date of Birth*

(MM/DD/YYYY)

Phone Number*

Pump User Email Address*

Serial Number of Remote Controller (if available)

Where to find your serial number?

Street Address

City

State

Zip Code

Country*