Business partners application


westmedizin.com • For business partners

Having filled in the following application for cooperation, you will receive the access to a confidential information and to the information we send to the partners cooperating with us.

BUSINESS PARTNERS APPLICATION

icon_doc* - Marked fields are mandatory
1. Name of the firm*:
2. Full Name of the head of the firm*:
3. Phone (with area code)*:

Fax:
4. E-mail*:
5. General information and the purpose of establishing contact with our firm*:
- Your work status
- Are you planning to send patients in Germany for medical treatment?
- Have you collaborated with our firm before?
- Which is your interest – medical treatment, medical checkup, raising the level of your skill?
- Information required ?
- Special whishes
6. Your message:
7. The contact person*:
Date and place of filling application: