Customer Referral Program

Step 1: Input Your Information

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / 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 NameLast Name

New Buyer's Address*

Street Address

Street Address Line 2

CityState / 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.
*Affiliates must be current and active.
*30-day money back guarantee, we need to add that a 10% restocking fee will still be assessed.

*If you make a second referral within the same calendar year, please expect to be asked to fill out a W-9 form for tax reporting purposes.