If you want to know more about pump technology and continuous glucose monitoring or if you are an existing pumper and want to learn about new Paradigm® systems, please fill out and submit this form today to get your FREE Info Pack.
* Required Fields
How did you hear about this site?*:
Patient First Name
(if not same as above):
Patient Last Name
(if not same as above):
Address Line 1*:
Address Line 2:
Preferred Method of communication
to receive future information:
Your Diabetes History
By giving us some background about you and your diabetes, we may be able to better provide information specific to your needs.
Who is the Patient?:
Age of Person diagnosed with diabetes:
What type of diabetes does this person have? :
How often is this person currently injecting insulin? :
Is the person living with diabetes currently using an insulin pump:
If yes, which company is your pump from:
Please check the box if the person living with diabetes is currently using Continuous Glucose Monitoring:
Insurance Verification is where our experts can help you determine available coverage from your private, public or group health plan.
Check here to complete the insurance process:
* The insurance verification process will require you to have Insurance Information ready
By submitting this form you are consenting to and confirm the following:
That Medtronic can communicate with you regarding our diabetes products by telephone, fax, mail and/or e-mail.
That Medtronic stores information, including personal health information, on systems located outside of Canada.
That you grant Medtronic of Canada permission to send you updates on diabetes and diabetes technology. You may revoke this permission at any time by emailing firstname.lastname@example.org
Select the product(s) you are interested in finding out your insurance coverage:* *Continuious Glucose Montioring (CGM)
Patient Birthdate*: (mm/dd/yyyy)
The Patient is also the primary insurance plan member:
Plan Member First Name*:
Plan Member Last Name*:
Plan Member Birthdate*: (mm/dd/yyyy)
Patient Relationship to Plan Member*:
ID/ Certificate #:
Drug Card #:
Physician Name (Diabetes Specialist)*:
Authorized By (Initials)*:
I authorize the Reimbursement Assistance Centre (RAC) and Medtronic to act, investigate and determine on my behalf or that of my spouse or dependent, any and all information related to my insurance coverage and its conditions as it relates to medical devices or other applicable benefits as it would relate to my care. I acknowledge that in acting on my benefit coverage that RAC and Medtronic will need to contact my insurer, or that of my spouse, and my doctor. In order to assist the RAC and Medtronic, I hereby submit the background information provided. I further authorize the RAC and Medtronic to act, investigate and determine on my behalf or that of my spouse or dependent, any benefits or coverage that may be available through my employer. I understand that my employer will not contacted unless I choose to appeal the level of coverage provided by my private or group insurance plan.
Other Questions or Comments:
Secondary Insurance Plan
The Patient is also the secondary insurance plan member: