Pulse Oximeter Purchase Form

Lifebox Pulse Oximeter – Purchase Form

We want to make it as easy as possible for you to receive your oximeters. Please respond to the following questions and we will start the work to process your order. A proforma invoice will then be sent to your attention for payment.

Name of purchaser(Required)

First Last

Purchasing organization(Required)

Recipient organization(Required)

Recipient’s mobile Phone(Required)

Email address (purchaser)(Required)

Email address (recipient)(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Shipping address (business or academic) Note this cannot be a P.O. Box address

Name and location of facility where oximeters will be used

(if different from shipping address)

How many Lifebox oximeter packages (containing 1 adult and 1 paediatric probe) would you like to order?(Required)

How many spare probes each would you like to order?

Adult (4 months +)

Neonatal wrap:

Ear clip:

Pediatric:

Payment mode(Required)

Bank transfer

PayPal

Please describe any special import control regulations for bringing medical equipment into your country.

Any other special instruction for delivery of oximeters?

Please confirm that you are willing to accept fees related to importation of this equipment (duties, taxes, etc.)(Required)

Yes

Pulse Oximeter Purchase Form

Lifebox Pulse Oximeter – Purchase Form

How many spare probes each would you like to order?

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