New FRx Defibrillator and Accessories

Please complete the following form to replace your affected unit with a new FRx with free carry case, 1 set of pads, battery and 5-year warranty. Philips will verify that the serial numbers you list on this form are part of the recall, and that your shipping address is in the US or Canada. The new FRx and accessories will be sent to you along with a return-addressed prepaid FEDEX shipping label. The new FRx and accessories are yours to keep. Please follow the packaging instructions that come with your new FRx to send back, free of charge, your original recalled defibrillator only (do not return the carry case or any accessories).

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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 select your country:

4. If other please specify:

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