Customer Referral Program

Step 1: Input Your Information

Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Email *

example@example.com

Contact Number *

Please enter a valid phone number.

Serial Number of Current Device* *

Step 2: Your Referral's Information

New Buyer's Full Name *

First Name Last Name

New Buyer's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

New Buyer's Email *

example@example.com

New Buyer's Contact Number *

Please enter a valid phone number.

In submitting this form, you acknowledge that you agree to the following terms and conditions:

*AVACEN reserves the right to cancel program at any time.
*Program available in U.S. & Canada only
*AVACEN reserves the right to not award payment given incorrect or inconsistent information.
*To earn a reward credit, referred customers must be new to AVACEN Medical.
*Reward credits will be issued following payment by referred customer as well as 30+ days of
ownership.
*AVACEN will contact reward recipients directly for payment options once qualified.
*Distributors must be current and active.