Patient details as known to the hospital, if different from above
Note: please allow 2 days for delivery
I have read and fully understand the Holiday Loan Contract. I will sign, scan and upload the contract.
Alternatively, you can also email your signed copy to email@example.com or post it to Ypsomed Ltd.,1 Park Court Riccall Road, Escrick, YO19 6ED, United Kingdom.
Please note:Loan mylife YpsoPumps will not be sent until we have received a signed copy.
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