MiniMed® Pro-set® Infusion Set Replacement Request Form

United States

MiniMed^® Pro-set^® Infusion Set
Replacement Request Form

To return any unused MiniMed^® Pro-set^® infusion sets, please complete the form below. Your infusion sets will be replaced for free with another Medtronic infusion set of your choice.

Child Online Privacy Protection Verification:
I am at least 13 years of age or older.*

Yes
No

STEP 1:

Tell us how many affected MiniMed^® Pro-set^® infusion sets you have on hand.

From the list below, locate your infusion set model number and enter how many full boxes and additional, individual infusion sets you have. (required)*:

Model Number	Number of Full Boxes (Boxes of 10)	Individual Infusion Sets
MMT-280
MMT-281
MMT-290
MMT-291

STEP 2:

From the table below, please choose what replacement infusion set you would like.

Important: If you don't see the infusion set that you would like in the table below, please call 1-800-646-4633 ext. 21063.

Infusion Set	Model	Description (cannula length, tubing length, connector)
MiniMed^® Quick-set^®	MMT-399	6 mm 23” Tubing Soft cannula MiniMed (P-cap) connector
	MMT-398	6 mm 43” Tubing Soft cannula MiniMed (P-cap) connector
	MMT-393	6 mm 23” Tubing Soft cannula Luer Lock Connector
MiniMed^® Mio^®	MMT-923	6 mm 23” Tubing Soft cannula Pink MiniMed (P-cap) connector
MiniMed^® Mio^®	MMT-943	6 mm 23” Tubing Soft cannula Blue MiniMed (P-cap) connector
MiniMed^® Silhouette^®	MMT-381	13 mm 23” Tubing Soft cannula MiniMed (P-cap) connector
	MMT-382	13 mm 43” Tubing Soft cannula MiniMed (P-cap) connector
	MMT-373	17 mm 23” Tubing Soft Cannula Luer Lock Connector
MiniMed^® Sure-T^®	MMT-864	6 mm 23” Tubing Steel Cannula MiniMed (P-cap) connector
	MMT-866	6 mm 32” Tubing Steel Cannula MiniMed (P-cap) connector
	MMT-863	6 mm 23” Tubing Steel Cannula Luer Lock Connector

STEP 3:

First Name*	Last Name*
Email*	Phone*
Address Line 1*	Address Line 2
City*	State*
Zip Code*	Date of Birth (MM/DD/YYYY)*
Pump Serial Number*	How do I find this?

MiniMed® Pro-set® Infusion SetReplacement Request Form

STEP 1:

STEP 2:

STEP 3:

Pump Serial Number Location

MiniMed^® Pro-set^® Infusion Set
Replacement Request Form