VAT Exemption Declaration
Please select which device or devices you wish to purchase. If you qualify for VAT Exemption an invoice and payment link will be sent to your provided email address.
*
Mighty Medic
Mighty Medic +
Volcano Medic 2
Discount code (This can not be entered later
Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Full description of your condition
*
Name of prescribing clinic:
*
Submit Form
Should be Empty: