TRAVEL LOANER AGREEMENT

In order for Medtronic Diabetes to provide you with a loaner insulin pump, please complete the information below and then click on the "submit" button at least two weeks prior to your scheduled departure. In your shipment, you will receive instructions for returning the insulin pump. Please be aware that the travel loaner insulin pump remains the property of Medtronic Diabetes. To help cover the cost of our loaner program, we must charge you a US $50 fee for shipping and handling. If the loaner pump is lost, stolen, or damaged, we must ask you to be responsible for the replacement cost of US $3,600.

Please understand that if we do not receive the loaner pump within two weeks of your estimated return date (not to exceed 90 days from the date of departure), we must apply the replacement cost charge of US $3,600 to your credit card (in either a lump sum or monthly installments, at our discretion).

For our active military customers, Medtronic will extend the loan period beyond the 90 days to accommodate the length of deployment . To request this extension, we require you to fax (210-775-7821) or email (rs.nrcatsup@medtronic.com) your military orders to us.

If Medtronic is experiencing inventory constraints of travel loaner pumps there may be delays in receiving your order. As a result, Medtronic strongly suggests you contact your Doctor to prepare a back-up plan if a travel loaner pump is not available prior to your departure.

* Required

Customer Information (Customer Wearing Device)

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Phone Number *

Alternate Phone Number  

Best time to call

Email Address *

Confirm Email Address *

Date of Birth *

Gender *

Male

Female

Are you Active Military needing an extension? If Yes, please provide details in the Travel Information Comments section below. *

Yes

No

Travel Information

Departure Date *[ 5/16/2019 ]

Estimated Return Date *[ 5/16/2019 ]

Travel Destination *

(If your estimated return date is more than 90 days from the date of departure, please provide details in the comment section)

Comments:

Payment Information

Credit Card Type *--None--VISA DISCOVER MASTERCARD AMERICAN EXPRESS

Credit Card Number *

Expiration Date (MM-YYYY)*--None--01 02 03 04 05 06 07 08 09 10 11 12 --None--2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030

Security Code / CCV * (?)

Cardholder Name

Billing Address *

City *

State *

Zip Code *

If any information entered in this section has changed since you last contacted Medtronic, please use the field below to explain.

Submit Order

I acknowledge that I have read and understand the charges associated with accepting a travel loaner insulin pump. Medicare beneficiaries acknowledge that they understand that the above-mentioned charges are not covered by Medicare. By accepting this loaner insulin pump, I am agreeing to be financially responsible for the above charges.

Submit

NOTE: A valid prescription is required for all medical devices. If you do not have a valid prescription on file you will be required to provide one in order for us to process your request. Is a Prescription Needed?

Please click "submit" only one time. It may take a few moments to process your request.

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