SERVICE

Application form:

Please complete and submit the application form below. We will contact you as soon as possible – no later than the next workings day!

Name and surname of the applicant:*:

Name of company*:

Tax number*:

Phone number*:

Email*:

Device installation address* - street:

Device installation address* - postal code:

Device installation address* - city:

Medical facility open hours*:

Device model*:

Serial number (SN)*:

Description of fault*:

Is the device under the warranty?:*
YesNo

A copy of invoice is required for warranty service. Please upload the file:

I have read the Information on the protection of personal data and I consent to the processing of my personal data in accordance with the Act of August 29, 1997 on the protection of personal data (Journal of Laws of 2014, item 1182, as amended) in the scope provided in the form, in order to provide the service.*

I have read and accept the Terms of Service of MEDIF LLP.*

*Required fields