HeartStart Defibrillator Replacement

Please complete the following form to receive a replacement defibrillator. Philips will verify that the serial numbers you list are part of the recall, and that your shipping address is in the US or Canada. A replacement device will be sent to you along with a return-addressed prepaid FEDEX shipping label. The replacement defibrillator is yours to keep. Please follow the packaging/shipping instructions that come with your replacement defibrillator to send back, free of charge, your original recalled defibrillator only (do not return the carry case or any accessories).

* Indicates required field.

PERSONAL INFORMATION

* Salutation	Professor Doctor Mr. Mrs. Ms
* First Name
*Last Name
Position/Title
*Company/Institution
*Address
Address 2
*City
*State
*Post/Zip
*Telephone
*Email
*Email Again

QUESTIONS

* 1. Enter the serial number(s) of the affected device(s):

* 2. Have you experienced any problems with your device(s)?

* 3. Please choose your country:

4. If Other, please specifiy:

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