Patient Information
The “patient” is the individual with the implanted device.
Date of Birth (mandatory)
Pacemaker or Defibrillator Device Model/Serial Number
The Pacemaker or Defibrillator Model/Serial number is listed on your Implanted Medical Device ID card. Please refer to your ID card for the following information. If you have lost your ID card, please call for assistance.
Entered Value is:
Carer/Advocate
If you are submitting this request on behalf of someone else, please complete the Carer/Advocate fields. The Carer/Advocate will be contacted if there is a problem with the order information.
Shipping Address
Enter the address where the 4G USB cellular adapter should be shipped.
Select State
New South Wales (NSW)
Queensland (QLD)
South Australia (SA)
Tasmania (TAS)
Victoria (VIC)
Western Australia (WA)
Australian Capital Territory (ACT)
Northern Territory (NT)
Northland
Auckland
Waikato
Bay of Plenty
Gisborne
Hawkes Bay
Taranaki
Whanganui-Manawatu
Wellington
Nelson-Tasman
Marlborough
West Coast
Canterbury
Otago
Southland
State (mandatory)
Please select a state.
Select Country
Australia
New Zealand
Country (mandatory)