I (Full Name of person for whom VAT Exemption is claimed) *

Of (Address) *

I declare that I am chronically sick or have a disabling condition by reason of: (give full and specific description of your condition) e.g. Stress Incontinence, Urinary Incontinence, Vaginal Wall Prolapse. *

Telephone Number (In case we need to contact you) *

Email Address (In case we need to contact you) *

* Required Fields