Name

Email

Please re-type your email address
(sometimes it is typed incorrectly the
first time, and we are unable to respond)

Phone number  (xxx-xxx-xxxx)

Best time to call

Were you implanted with a Guidant defibrillator?
Yes    No

If yes, when?

What is your defibrillator's model number?

Has your defibrillator failed to work?
Yes    No

If yes, please describe failure

Has your defibrillator been replaced?
Yes    No

If yes, when?

Additional comments