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Facility Name (*)

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Facility Number (*)

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Select Issue Type (*)

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Was a Patient Affected by This Issue? (*)

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If Yes, please call Clinical Support at (800) 315-3287, then complete the form.

Pump Model (*)

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Pump Serial Number (*)

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Description of Issue (*)

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Person Reporting the Issue (*)

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Your Email (*)

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Your Phone Number (*)

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Tubing Available for Return with Pump? (*)

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Tubing or Set Model Number (*)

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Tubing or Set Lot Number (*)

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Drug Being Infused (*)

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Statement on Issue (*)

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