Sign Up for a Biomental Botinnox-treatment or an Botinnox Intensive Treatment by e-mail:
Please fill in the empty address fields, print the form, sign and mail or fax it to +49 2132 9958993. To order a hotel, please click on hotel. For our adress please click on adress. For the Biomental Training in your hotel you need a mp3 player or a GSM with an email account or a PC and an USB-stick and headphones.
First name:
Last name:
ZIP:
City:
Street no.:
Email-adress:
Phone-No.:

I hereby sign up for an Botinnox-Treatment (5-days relaxation à 60 min. - optical and acustical respiratory biofeedback, light- and soundtherapy and videotherapy plus one lower concentrated Botox-injection each day) or

an Botinnox Intensive Treatment (5 more concentrated Botox-injections in 5 days). I have reserved the treatment by phone (00492132 9958995).

At the same time I have transferred 1500,- Euro to the account:
Dr. Hans Greuel
Deutsche Bank
IBAN:DE93300700240046050100
BIC: DEUTDEDBDUE

I agree with the privacy agreements.

Date/Signature