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優等生會員保固與優惠券申請
因官網目前進行優化作業
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姓名:
*
Your answer
電話:
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Your answer
Email:
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Your answer
姓別:
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Choose
男 Male
女 Female
不公開
生日:
MM
/
DD
/
YYYY
健康狀況:
*
T1糖尿病
T2糖尿病
妊娠糖尿病
無糖尿病
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購買機型:
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Contour Plus 優安進
Contour Plus One 優安進1
Contour Plus ELITE優安進領航
Contour TS優安康
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機身編號(例如:SN 2722123)
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取得通路:
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診所
藥局
醫院
醫療器材行
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取得通路名稱
(如:台大醫院):
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購買日期:
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MM
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DD
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YYYY
是否申請優惠券:
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是,我要申請優惠券(請詳細填妥寄送地址)
否,我不申請優惠券
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其他備註:
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