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Medtronic Pharmacy Program


SNPG Medtronic Pharmacy Program

Please complete the following form if you are a current insulin pump user or if you use insulin to manage your diabetes and would like to know more about the benefits of insulin pump technology.

*a red asterisk indicates a response is required

Medtronic Pharmacy Program

Informed Consent

By completing the Medtronic of Canada Ltd questionnaire, your information is kept strictly confidential. This is consistent with the consented terms for collection, use, distribution and disclosure of your information by MHCSI – Managed Health Care Services Inc., to provide Medtronic of Canada Ltd contact information in the form of data.

We use technology and strict security standards to ensure that all personal health information is protected against unauthorized access, disclosure, inappropriate alteration, or misuse. We use a variety of different safeguards to protect the security of your personal health information, including locked facilities, alarm systems and information technology such as “fire walls”. We also restrict access to your personal health information to MHCSI, your designated pharmacy as well as Medtronic of Canada Ltd., keeping records required by law and ensuring that you are provided with quality care.

• Medtronic will communicate with you regarding our diabetes products by mail, email or text message.
• Medtronic stores information, including personal health information, on systems located outside of Canada. The information you have provided will be used for the purposes of product notification, service updates, provisions of customer services or other inquiries from you
• Medtronic privacy policy. Go to
• You grant Medtronic of Canada permission to send you updates on diabetes and diabetes technology
• You may revoke this permission at any time by emailing
• Medtronic respects the confidentiality of personal information. We assure you we will not share your personal information, except as otherwise noted in our privacy policy

By clicking below, you are agreeing to the above statements and release your information to be used only as specified above and consent to have the above information submitted to Medtronic of Canada, Ltd., so that they can contact you with information on diabetes, diabetes technologies, education and updates.

Please enter DD/MM/YYYY

Contact Information