Product interest request form Thank you for your interest in Medtronic diabetes products and services. Please complete the items below so that we may provide you helpful information regarding our diabetes therapies. Are you an existing Medtronic customer? Yes No Check your upgrade eligibility Follow these 3 simple steps: Sign into your account at www.diabetes.shop/devices Under Devices and products, select the “Check upgrade eligibility” button. See which program you're eligible for and then submit an upgrade request! Check eligibility or upgrade If you are ready to place your order, please visit Diabetes.shop. If you are not ready or need more information, call a Medtronic representative at 888-350-5440 or check out our upgrade programs. CLICK HERE for device upgrade information Type of diabetes? Type 1 diabetes Type 2 diabetes Does not apply Other: Gestational, Slow Onset, LADA, Prediabetes Who is living with diabetes? Myself My Child A Family Member My Friend My Patient Other How is your diabetes currently managed? 3 or more shots of insulin per day 2 shots of insulin per day 1 insulin injection a day or oral medication Diet and exercise Medtronic Insulin Pump Other Insulin Pump Reason for not using an insulin pump? Don’t want to have a device attached to my body Too complicated Don’t think insurance will cover it Doctor won’t prescribe insulin pump for me Don’t want other people to know I have diabetes Out-of-pocket costs too high Concerned the pump would malfunction Pumps don’t hold enough insulin for my needs Other How long have you owned your Medtronic pump? Less than 4 years More than 4 years Which product(s) and/or service(s) are you interested in? MiniMed™ 780G Insulin Pump System MiniMed™ 630G Insulin Pump System Continuous Glucose Monitoring (CGM) i-Port Advance™ Injection Port InPen™ Smart Insulin Pen First name Last name Email Phone ZIP code Country / region United StatesAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic of TheCook IslandsCosta RicaCote D'ivoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-bissauGuyanaHaitiHeard Island and Mcdonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic ofIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMOMacedonia, The Former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of MoldovaReunionRomaniaRussian FederationRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and The GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and The South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanThailandTimor-lesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited Republic of TanzaniaUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe This form is for customers in the Unites States only. For more information about our products in your region please see our list of international locations. How can we communicate with you? Subscribe to our newsletter, News to Infuse You indicated that you’re not using insulin to manage your diabetes. Our insulin pumps are approved for the continuous delivery of insulin, so this device may not be a good fit for you at this time. We have other resources that may be helpful for you: Sign-up to receive our newsletter for monthly updates and tips Visit our blog to read helpful diabetes stories and perspective from the community Connect with a product ambassador to have a discussion with a real person living with diabetes If your circumstances change, please check back with us and we’d be happy to discuss therapy options that may fit your needs.