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Facturation Contact: VAC/ACC DND/DDN NIHB/SSNA RCMP/GRC WSBC WCB AB WCB SK WCB MB WSIB CSST WHSCC OTHER/AUTRE: Client or Claim NO/ NO de client: Patient Information / Information patient First Name / Pr nom Last Name / Nom Model Serial NO Accessories Mod le NO de s rie Accessoires WARRANTY INFORMATION / INFORMATION SUR LA GARANTIE Please check all applicable boxes / S.V.P. cocher les cases applicables In Warranty / Sous garan.

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