* First Name 

   * Last Name 

   * Email 

   * Phone 

Cell Phone 

Date patient began using the H-Tron Insulin Pump:

Date patient stopped using the H-Tron Insulin Pump:

Were you diagnosed with HYPERGLYCEMIA after using H-Tron Insulin Pump?Yes
No

Were you diagnosed with HYPOGLYCEMIA after using H-Tron Insulin Pump?Yes
No

What medical condition prompted the use of the device?

Please describe any problems or injuries caused by the product:

Date adverse symptoms or injuries were noticed:

No Yes, I agree to the Parker Waichman LLP disclaimers. Click here to review.

Yes, I would like to receive the Parker Waichman LLP monthly newsletter, InjuryAlert.