Form

Medifab is currently building a global network of distributors. Fill out this online form and we will direct your enquiry to your local distributor. Or, check out our distributors page to find your nearest distributor.

Purchase Method *

Funding body – please send me a quotation for my application Charity – please send me a quotation for my application Self-purchase – please send me a quotation Other – please describe

Purchase Method

Name *

First Name Last Name

Email *

Country *

Postcode *

Phone Number *

I am a... *

Company

Department

User/Client Name *

Age of User *

Tell us about the users needs so we can make recommendations

Base Options

4 Wheel Verve Pushchair Launcher Indoor Base Lunar Indoor Base Moon Rock Indoor Base

Accessories I need

Are there any special requirements or other additions needed to meet the needs better?

I agree to Medifab terms & conditions *

Yes

Disclaimer: We advise you to seek professional medical assistance in any purchase of Medifab products. Every effort will be made to help you purchase this product, however often we need to finalise detail to ensure we provide the right equipment for the right purpose in meeting the users need correctly. If you are a dealer, business or otherwise individual without a contract agreement with Medifab Limited we have every right to refuse your purchase. Medifab Limited has every right to refuse your purchase for any reason.