Registration for the Intera 3000™ Hepatic Artery Infusion Pump

Register your device

Electronic implant tracking - required by the FDA

Intera 3000 HAI pump implanted

Implant date

Model number

Model number for all submissions is AP-03000H

Serial number

Reason for implant

Select an item

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

Implant hospital name

Implant hospital address

Implant hospital city

Implant hospital state

Implant hospital zip code

Implant hospital phone number

Implant physician information

Implant physician first name

Implant physician last name

NPI #

Implant physician address

Implant physician city

Implant physician state

Implant physician zip code

Implant physician phone number

Refilling physician information

Refilling physician first name

Refilling physician last name

NPI #

Refilling physician address

Refilling physician city

Refilling physician state

Refilling physician zip code

Refilling physician phone number

Submitted by

Submitter name

Submitter phone number

- If the refilling physician is not known, please consult with the surgical oncologist.

- Intera clinical call line: 800-660-2660

* required

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