US-FLC45-260011 Vitals Legacy Promotional Offer 2026

Promo Redemption Information

Facility Information

Facility Name *This question is required.

Parent Organization

Street Address *This question is required.

Apt/Suite/Office

City *This question is required.

State / Province *This question is required.

Postal / Zip Code *This question is required.

1. Contact Information

Contact Function/Title

First Name *This question is required.

Last Name *This question is required.

Phone Number *This question is required.

Tax ID *This question is required.

Email Address *This question is required. This question requires a valid email address.

2. Product Shipping AddressNo PO Box shipments allowed

Facility Name *This question is required.

Attention

Street Address *This question is required.

Apt/Suite/Office

City *This question is required.

State / Province *This question is required.

Postal / Zip Code *This question is required.

3. Purchase/Redemption Information

Baxter Rep Name

Distributor Company

4. Upload proof of purchase invoice and W-9. *This question is required.(REQUIRED. Submissions without required documentation will not be processed.)

5. Yes, I confirm that I have read and reviewed the Privacy Notice. *This question is required.