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Alzheimer's disease
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Client / Billing details
Name and Surname:
Name of company:
ID No.:
Street :
City/town:
Post code:
Vyšetřovaná osoba
Name and Surname:
Birthdate:
E-mail address:
Telefon:
Street :
City/town:
Post code:
If a person is under the age of 18, it is necessary to fill in the details of the legal representative person
Details of legal representative person
Name and Surname:
Street :
City/town:
Post code:
Relationship to the minor:
Address for delivery of the collection kit (if different from the address of the investigated person)
Address for delivery of the collection kit
Name and Surname:
Street :
City/town:
Post code:
I agree
Terms and Condition
Mám slevový kód
Mám slevový kód:
create and pay an order
Creating an Order
Rekapitulace objednávky
Payment of the order
Order confirmation
