URGENT MEDICAL DEVICE RESPONSE FORM
PHILIPS HEALTHCARE

This form consists of 4 pages. Please make sure to SUBMIT SURVEY on page 4.

Reference: M5071A and M5072A

Instructions: Please complete no later than 30 days from receipt. Completing this form confirms receipts of the Urgent Medical Device Correction notice, understanding of the issue and required actions to be taken.

To learn more about Philips' approach to privacy, please visit https://www.philips.com/a-w/privacy.html.

IF YOU HAVE ALREADY RETURNED THE PAPER ACKNOWLEGEMENT, YOU DO NOT NEED TO COMPLETE THIS FORM.

Tell us about yourself

* required

On the Urgent Medical Device Correction letter or postcard you received, please tell us your unique customer code. See example below.

NOTE: This is not your order number or invoice number, this is a specific number assigned to you and is printed on your Medical Device Correction letter or postcard.

If you do not have your unique customer code, please contact your local Philips Representative or call 800-263-3342 and exit this survey.

Customer Code *

Is the AED owner's name or address different than the address on your letter/postcard? *

Current owner name and/or name of business *

Current address *

City *

Zip code *

Email address *

Phone number *

xxx-xxx-xxxx

Do you currently own a Philips HeartStart OnSite or HeartStart Home AED? *

If you no longer own the AED, will you explain (for example: transferred to someone else, etc.):