Title
Mr. Mrs. Ms. Miss Mr. & Mrs. Dr.

* First Name

* Last Name

* Email Address

* Phone Number

Cell Phone Number

Office Phone Number

Street Address

Apartment/Suite

City

State
-Choose State- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming -Puerto Rico- -U.S. Virgin Islands- -Other-

Zip Code

Please provide the best method and times to contact you:

Date of birth of person injured
(mm-dd-yyyy):

Which Medtronic Defibrillator was implanted?
Medtronic Marquis Medtronic Maximo Medtronic InSync Medtronic Micro Jewel Medtronic Gem Other Not sure

If other, what is the name of the defibrillator that was implanted?

Date the device was implanted:

Is the device still implanted?
Yes
No

What medical condition prompted the use of the device?

Please describe any problems or injuries caused by the device:

Other Info:

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