Happy Hips Service Contact Form Helping babies with hip dysplasia Happy Hips Service Application Form Do you want to request a Maxi-Cosi Opal HD? Request it directly through the application form below! Any question on our Happy Hips Service? Please use the normal Contact Form and select the subject "Happy Hips Service".! Personal Information GenderMaleFemale First Name Last Name Street Number Addition Postal Code City Contact Information Phone number E-mail Information on your baby Number of months that treatment is required Name of the baby Birthday of your child Age (in months) GenderMaleFemale Weight (in kg) Length (in cm) Upload Photo or Hospital Letter (Photo of your baby wearing the cast or brace or Hospital Letter) General Information Do you already have a Maxi-Cosi car seat?YesNo Which other brand? In which car are you going to use the Opal HD? Please specify make, model and year of manufacture Would you like to subscribe to our newsletter?YesNo Are you pregnant?YesNo Your due date? How many children do you have?Please select... 0 1 2 3 4 5 6 7 8 9 10 I agree with the privacy conditions*. reCAPTCHA helps prevent automated form spam. The submit button will be disabled until you complete the CAPTCHA. Contact Information
