Sign Up for a Biomental-Teleclinic-Treatment
Please fill in the empty address fields, print the form, sign and mail or fax it to +49 2132 9958993.
First name:
Last name:
ZIP:
City:
Street no.:
Email-adress:
Phone-No.:
I hereby sign up for a 10-days-Biomental-Teleclinic-Therapy. Under the e-mail adress: drhansgreuel@web.de I booked the first lession.
At the same time I have transferred 925,- Euro to the account:
Dr. Hans Greuel
Deutsche Bank
IBAN:DE93300700240046050100
BIC: DEUTDEDBDUE

I agree with the privacy agreements.

Date/Signature