Upgrade to the MiniMed™ 670G System with SmartGuard™ Technology

1: First Name *

2: Last Name *

3: Are you the pump user? (If yes, skip to question 7) * -- Please Select -- Yes No

4: Pump User First Name (Only if you answered No to question 3)

5: Pump User Last Name (Only if you answered No to question 3)

6: Pump User Date of Birth

7: Phone *

8: Email Address *

9: Address *

10: City *

11: Province *

12: Postal Code *

13: Shipping address same as above? (We are not able to ship to PO boxes) * -- Please Select -- Yes No

14: Shipping Address (Only if you answered No to question 13)

15: Shipping City (Only if you answered No to question 13)

16: Shipping Province (Only if you answered No to question 13)

17: Shipping Postal Code (Only if you answered No to question 13)

18: Current Pump Serial Number *

19: Physician First Name (Diabetes Specialist)

20: Physician Last Name (Diabetes Specialist) *

Please review and acknowledge below to proceed:
** By placing an order for a new MiniMed 670G System upgrade at $1399, I acknowledge the following: I understand:

• The cost of the Pathway Program to the MiniMed 670G Insulin pump is $1399.
• Continuous glucose monitoring starter kits can be purchased for an additional amount.
• The remainder of the warranty on my current pump will transfer to my new MiniMed 670G system (i.e I will have the same warranty end date).
• The MiniMed 670G system cannot be returned once received.
• I must return my current in-warranty Medtronic pump to Medtronic within 30 days of receiving my new Medtronic MiniMed 670G system. (*Medtronic will provide a return waybill with shipment of your new system to enable easy and no cost return. Please contact Medtronic Customer Service at 1.800.284.4416 if your training is delayed.) Please note that the Medtronic infusion sets and reservoirs you are currently using are compatible with the MiniMed 670G.
• If I do not return my current in-warranty Medtronic pump, I will be invoiced $7,200 CDN for the new MiniMed 670G System and that I will be responsible for payment of this amount should I decide not to return my current pump to Medtronic.

In order for us to be able to contact you, we need your consent to the following:

• Medtronic can communicate with you regarding our diabetes products by telephone, text, fax, mail and/or e-mail.
• That you have read and are aware of our privacy policy.
• That you grant Medtronic of Canada permission to send you updates on diabetes and diabetes technology..
• That Medtronic stores information, including personal health information, on systems located outside of Canada.
• You may revoke this permission at any time by emailing medtronicdiabetescc@medtronic.com