Customer registration

If you are not already a registered medlog customer, please fill in this form carefully.

Once you have sent off the form you will receive confirmation via e-mail.
All fields marked with an * are required.

Key customer details


Company  
Salutation*   Title  
First  
name*  
Surname*  
Address*  
Postcode  
(ZIP)*  
Town/City*  
Email*   Telephone*  
Telefax   Mobile  
Collection  
availability  
from*  
Collection  
availability  
until*  
 
Access  
route*  
 
Your    
inquiry*  
 


Direct debit authorisation


If you wish to grant direct debit authorisation, please fill in this form accurately and completely. You will be sent a separate e-mail which we request you to sign and fax back to us.

BIC:   IBAN.:  
Bank  
Account-  
holder:  

Collection point


Collection point is different to the above address.

Company*  
Salutation*   Title*  
First name*  
Surname*  
Address*  
Postcode*   Town/city*  
E-mail*   Telephone*  
Collection availability    
from*  
Collection availability    
until*  
 
Access route*  

Inquiry regarding orders for consignment transportation and price information.
Shipment Details: Receiver:
Quantity*   Name*  
Weight*   Contact  
Dimensions in    
cm*  
Street*  
Worth*   ZIP*  
Table of contents   Town / City*  
Delivery -   
date*  
Telephone*  
Insurance*   Comments*  
I would like to be advised per telephone. Please call me!
I agree to receive the medlog newsletter.