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t:slim X2™ Insulin Pump Travel Loan
Come Fly with Me
Please complete this application form to initiate a travel t:slim X2 insulin pump loan
First name
*
Last name
*
Departure Date
*
Day
/
Month
/
Year
Return Date
*
Day
/
Month
/
Year
Destination of Travel
*
Please specify the country you will spend the most time in
t:slim X2 insulin pump serial number
Please note: this will only be offered to individuals covered by warranty
Email
*
Date of birth
*
Parent name (if applicable)
Phone number
*
International Phone number
Street address
*
Suburb
*
AU State
*
Please Select
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Postcode
*
Delivery Address
*
Please include street address, suburb, state and postcode.
Healthcare Provider Details
Healthcare Professional Name (if applicable)
Hospital/Clinic Name
AMSL Diabetes Territory Manager
By submitting this form:
You agree that you will
NOT
open the travel loan t:slim X2 insulin pump until instructed by AMSL Diabetes Technical Support.
You agree to operate the device as per usage instructions, indications, warranty and
terms and conditions
.
You have read, understood, and agreed to the
terms and conditions
.
You have confirmed that you are willing to pay a refundable $50 deposit as detailed in the
terms and conditions
.
I confirm that I am traveling overseas with my t:slim X2 insulin pump
*
Submit