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Complimentary Device Request

Who are you?

Practitioner

Practitioner & parent of a child requiring a device

Parent or caregiver

Patient

Content creator / ambassador

Charitable organisation

Other

Your details

First & last name

Email

Instagram Handle

i.e. @myomunchee - if not applicable, enter N/A

Country

Shipping address

Phone number

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What device sizes are you requesting?

If you are after more than 1 device, select all that apply.

BEBE (6 - 18 months)

MINI (18 months - 4 years)

JUNIOR (4 - 8 years)

TWEEN (8 - 14 years)

ADULT (14+ years)

Not sure

Who is it for?

Myself

My child

A patient/client

Clinic demonstration / training

Charitable organisation

Other

How many complimentary devices are you requesting?

Why are you requesting a complimentary device?

i.e. describe the initiative or cause; who will benefit & how; expected timeframe for the initiative; how will the Myo Munchee be used or distributed;

Do you know how to use a Myo Munchee?

No: I do not know how they work, or will not have anyone around me that can support me should I require clinical assistance.

Maybe: I have gone through the website extensively and am generally good at figuring things out, or I know someone that may be able to support / guide me if I run into issues.

Yes: I have either used one before / know how they work, or have a practitioner that knows the device and will be able to guide me if I require additional assistance.

Are there opportunities for collaboration and follow-up?

Product feedback

Testimonial

Social media post

Patient/family feedback

Photographs &/or video content

No or not sure

No formal follow-up

Other

Final agreements

I understand that complimentary device requests are reviewed on a case-by-case basis, and that once Myo Munchee’s annual complimentary device budget has been fully allocated, no further free devices can be provided.

I acknowledge that donated/complimentary Myo Munchee devices must be used in alignment with Myo Munchee’s usage guidelines.

I confirm that I have completed this form with honesty and integrity and all information provided is accurate at the time of submission

I understand Myo Munchee may contact me for follow-up using the contact information provided, and I will respond where required of me to do so.