TRAVEL LOANER AGREEMENT

In order for Medtronic Diabetes to provide you with a loaner insulin pump, please complete the information below and then click on the "submit" button at least two weeks prior to your scheduled departure. In your shipment, you will receive instructions for returning the insulin pump. Please be aware that the travel loaner insulin pump remains the property of Medtronic Diabetes. To help cover the cost of our loaner program, we must charge you a US $50 fee for shipping and handling. If the loaner pump is lost, stolen, or damaged, we must ask you to be responsible for the replacement cost of US $3,600.

Please understand that if we do not receive the loaner pump within two weeks of your estimated return date (not to exceed 90 days from the date of departure), we must apply the replacement cost charge of US $3,600 to your credit card (in either a lump sum or monthly installments, at our discretion).


* Required
Customer Information (Customer Wearing Device)
Travel Information
4/24/2014 ]
4/24/2014 ]

(If your estimated return date is more than 90 days from the date of departure, please provide details in the comment section)

Payment Information

If any information entered in this section has changed since you last contacted Medtronic, please use the field below to explain.

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Submit
NOTE: A valid prescription is required for all medical devices. If you do not have a valid prescription on file you will be required to provide one in order for us to process your request. Is a Prescription Needed?

Please click "submit" only one time. It may take a few moments to process your request.




By submitting this form, you are granting Medtronic MiniMed, Inc. ("Medtronic") permission to add your contact information to its database for sending you additional information and communications related to Medtronic products and therapies. You may revoke this permission at any time by sending a request in writing to: Medtronic MiniMed, Inc. c/o Customer Support, 18000 Devonshire Street, Northridge, CA 91325-1219

Medtronic respects and upholds the confidentiality of your personal information. We will not share your personal information with any third-parties, except as otherwise noted in our Website.

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