Registration for the Intera 3000™ Hepatic Artery Infusion Pump

Intera 3000 HAI pump explanted

Explant date

Initial Implant Date (of explant)

Model number

Model number for all submissions is AP-03000H

Serial number

Reason for explant

Select an item

Explant manufacturer

Patient information

Patient first name

Patient last name

Patient DOB

Patient street address

Patient city

Patient state

Patient zip code

Patient country

Patient phone number

Patient email

Patient social security #

Hospital information

Explant hospital name

Explant hospital address

Explant hospital city

Explant hospital state

Explant hospital zip code

Explant hospital phone number

Explant physician information

Explant physician first name

Explant physician last name

NPI #

Explant physician address

Explant physician city

Explant physician state

Explant physician zip code

Explant physician phone number

Submitted by

Submitter name

Submitter phone number

- Intera clinical call line: 800-660-2660