* First Name 

   * Last Name 

   * Email 

   * Phone 

Cell Phone 

Date patient started using Minimed Insulin Infusion Set:

Date patient stopped using Minimed Insulin Infusion Set:

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:

Were you hospitalized as a result of your injuries? If so, please describe hospitalization:

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