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Order Form for clinicans staff

53 % discount

last and first name (patient) Female Male BARCODE


Please send the results to:
myself my physician
Name (physician):
Date of birth (DD/MM/YYYY): _____/_____/__________
Street, No.:
Street, No.: Withdrawal Time: ___ : ____
ZIP: City:
ZIP: City: Date (DD/MM): ____ /____
Material / Quantity CPDA / State: Country:
State: Country:
Heparin / EDTA / Phone:
Phone: 00 00
Serum /
Email:
Email:

I hereby declare that I wish to order medical services which might not be covered by my health insurance. I am aware of the
costs for the test material, logistics with DHL and all diagnostic parameters I wish to be tested for. I am aware that I have to
pay these costs myself and in advance. I agree that all laboratory parameters will be tested and charged by ArminLabs.

Date, Signature: .....


ArminLabs GmbH - CEO: Armin Schwarzbach MD PhD
Zirbelstrae 58, 2nd floor 86154 Augsburg Germany Phone: 0049 821 780 931 50 www.arminlabs.com
Email: info@arminlabs.com VATReg-No.: DE815543871 Amtsgericht Augsburg HRB 29350 page 1
Order Form for clinicans staff
53 % discount
If you use our recommended worldwide DHL medical express service, we will charge you 50.00 (incl. Test Kit
material). If you organize the shipment to ArminLabs by yourself, you will only be charged 5.00 for the Test Kit
material.

Depending on the payment option you select below, the costs either have to be included in the prepayment or
they will be charged to your Credit Card. If you choose to transfer the amount to our bank account in advance,
please make sure to do this early, as we wont be able to send out the results before receiving your payment.

DHL Medical Express service incl. material 50.00


or
Material only (self-organized shipment) 5.00

Diagnostic Parameters: _____._____ (please sum up the costs of all checked tests)

Total amount: _____._____ (please add the costs for material and/or DHL Medical Express)

Payment Options:
o Prepayment via bank transfer
IBAN: DE22 7205 0101 0030 5069 68; SWIFT-BIC: BYLADEM1AUG; Account-No.: 30506968
Bank-Details: Kreissparkasse Augsburg, Martin-Luther-Platz 5, 86150 Augsburg, GERMANY
Receiver: ArminLabs GmbH - Dr. Schwarzbach; Reference: Patients full name + DoB
Please state the patients full name and Date of Birth in the reference-field of the bank transfer !

o VISA (+2,95% fees)

o Mastercard (+2,95% fees)

o AMEX (+1,95% fees)

Credit Card Number:

Name as on credit card:

Expiration Date (MM/YY):

Card Validation Code (CVV):

Total Amount (as calculated above): _____._____

Total Amount (incl. Credit Card Fees): _____._____

In case of credit card payment, I agree that ArminLabs will charge my credit card with the Total Amount (incl.
Credit Card Fees).

Date, Signature:
ArminLabs GmbH - CEO: Armin Schwarzbach MD PhD
Zirbelstrae 58, 2nd floor 86154 Augsburg Germany Phone: 0049 821 780 931 50 www.arminlabs.com
Email: info@arminlabs.com VATReg-No.: DE815543871 Amtsgericht Augsburg HRB 29350 page 2

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