Requester's Lastname (required)

Requester’s Name (required)

Requester’s Email (required)

Requester’s Phone (required)

Patient’s Lastname (required)

Patient’s Name (required)

Patient’s Email (required)

Patient’s Phone (required)

Patient’s Address (required)

Patient’s Department (required)

Patient’s Province (required)

Patient’s City (required)

Patient’s Zip Code (required)

Patient’s Country (required)

Device Model (US$) (required)
CA720-HB ($599)CA720 ($649)CA720W ($699)CA820 ($749)CA820W ($799)BA725W ($949)BA825 ($969)BA825W ($1,049)ST725W ($1,149)ST730 ($1,349)ST730W ($1,399)SV825W ($1,599)ST830 ($1,799)ST830W ($1,899)AU730W ($1,599)AU830PRO ($2,149)

Quantity (required)

Payment Method (required)
Zelle US (No fees)Wire Transfer (Add $35)Credit Cards (add 3%)

Shipping to: (required)
ITH PeruPatient

Additional comments (optional)

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