Importance of Registering your Device
- The card provides contact information for the physician that implanted your device.
- The card provides a reference in the event you have to provide your medical history.
- The card’s reverse side includes information on commonly asked questions.
- The card’s reverse side provides contact information for St. Jude Medical/ AGA Medical.
Patient’s Last Name and Patient’s First Name: Please enter the patient’s name the way you would like it to be displayed on the identification card.
Gender: Indicate “M” for Male and “F” for Female.
Date of Birth: Indicate the patient’s date of birth as MM/DD/YYYY
Street Address, City, State or Province, Postal Code, and Country: Enter the patient’s mailing address. Please enter the complete address. All incomplete addresses and returned identification cards will be sent to the implanting physician to be distributed to the patient.
MPLS, MN 11111
Abcde 11th Street
Minneapolis, MN 11111
Implanting Physician Information
Indicate the Implanting Physician’s Last Name and the Implanting Physician’s First Name.
Please enter the complete name of the hospital where the device was implanted.
University of Minnesota Amplatz Children's Hospital
Date of Implant: Indicate the date that the device was implanted as MM/DD/YYYY
Product/REF Number, Lot Number, and Serial Number/SN: Please use your temporary identification card or contact your clinician to obtain the device information needed to complete the product information.
Preferred contact method: Phone or Email: Please indicate the best way to reach you if there are any questions regarding the submitted information.
Additional Information Regarding the Implant Registration Form
Identification Cards are created for the following devices:
- AMPLATZER® Septal Occluder
- AMPLATZER® Multi-Fenestrated Septal Occluder – "Cribriform"
- AMPLATZER® Duct Occluder
- AMPLATZER® Muscular VSD Occluder
For information regarding your device’s
Contact information regarding the Implant Registration Form
St. Jude Medical
5050 Nathan Lane North
Plymouth, MN 55442
ATTN: Patient ID Cards
Toll Free: 1-888-546-4407