VAT Exempt Form - MBM healthcare

Client Name

First

Last

Client Email

Client Address

Client Number

Buyer Type (Individual or Charity buying medical equipment)

Individual
Charity

Medical Equipment Being Purchased

Brief description of your condition or disability

Eligibility — nature of condition (Please tick the statement that applies to you)

I have a physical or mental impairment that has a long-term and substantial adverse effect on my ability to carry out everyday activities (e.g. mobility impairment, arthritis, dementia)
I have a condition that the medical profession treats as a chronic sickness (e.g. diabetes, MS, Parkinson's disease)
I am terminally ill

Brief description of your condition or disability

Name the condition

Declaration