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Please select the applicable option(s) to populate the form for submission.
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Was your device implanted in the United States and/or is it being managed by a physician in the United States?*
This form is only for devices that were implanted in the United States and/or are being managed by a physician in the United States. Please reach out to your Healthcare Provider for questions regarding your device registration and ID Card.
I am a*
Please check all that apply:
We understand that the Medtronic device was replaced or removed. In order to update the patient record, please call Patient Registration Services at 800-551-5544. It is important for us to capture all the necessary information for the device replacement/removal in order to update your record and our mailing list.
PATIENT INFORMATION
SSN INFORMATION
MEDTRONIC DEVICE INFORMATION
PHYSICIAN INFORMATION
SUBMITTER INFORMATION
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Your information will be protected in accordance with our privacy notice.