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CPAP Free Trial Form

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Name*

Tel*

Email*

Shipping address

Which model do you want to try?

Have you undergone a sleep test before?*
YesNo

If no, do you want to do a sleep test before testing the CPAP machine?*
YesNo

Your AHI

Doctor’s name

Hospital’s name

Do you apply for CPAP reimbursement? (Only for government officers)*
YesNo

How do you know us?*
GoogleFacebookOhter Internet channelsDoctor's recommendationHospitalFrom your friendBrochureSeminars or eventsOthers

Additional message (if any)

*Required fields (cannot leave blank)

Conditions:

  • If your address is outside Bangkok area, we need to collect 3,000 Baht deposit money.
  • You can try the machine for maximum 7 days.

I accept the above conditions.