Patient Device Registration / ID Card

To ensure timely processing of your identification card, please submit completed information for ALL sections of the Implant Registration Form. Follow the Instructions below.

Register your Device.

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 Information

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.

Incomplete Address:
John Smith
Abcde 11th
MPLS, MN 11111
US
Complete Address:
John Smith
Abcde 11th Street
Minneapolis, MN 11111
United States

Implanting Physician Information

Indicate the Implanting Physician’s Last Name and the Implanting Physician’s First Name.

Institution

Please enter the complete name of the hospital where the device was implanted.

Incomplete Name:
Children’s Hospital
Complete Name:
University of Minnesota Amplatz Children's Hospital
 

Product Information

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.

Contact 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
MRI Compatibility

Contact information regarding the Implant Registration Form
St. Jude Medical
5050 Nathan Lane North
Plymouth, MN 55442
USA
ATTN: Patient ID Cards

Toll Free: 1-888-546-4407
Phone: 1-763-513-9227
Fax: 1-763-647-5929

Email: PatientID@amplatzer.com

Quick Links for Patients

 

Safety Information

 

Contact Us:
United States

Amplatzer Products
5050 Nathan Lane North
Plymouth, MN 55442
USA

Toll Free: 1-888-546-4407
Phone: 1-763-513-9227
Fax: 1-763-513-9226