Order form

Fields marked by asterisk (*) are obligatory.

Customer Information

First Name & Last Name*

Company Name (optional)

Address

Street Address (house number, apartment number)*

Postal/ZIP Code*

City*

Province/State

Country*

Phone Number

Area Code*

Phone number*

E-mail*

Please choose purchase document type

Shipping Address (if is different than above)

First Name & Last Name Postal/ZIP Code City Street Address Street Address line 2 Province / State Country

Please be informed that by sending this Order Form you accept the processing of your personal data necessary to accomplished this order only (in accordance to the Data Protection Act 1998 and relevant legislation (unified text: Journal of Laws of 2014, item 1182 with amendments). All data received are confidential. You have right to inspect, correct and erase your personal data.

If you would wish to receive from us an additional information regarding new products, sales promotions, additional scientific information, please tick an appropriate option.

Yes, I want to receive

No, I do not want to receive

Order Specification

Legenda

Sekcja 1

Sekcja 2

Sekcja 3

Sekcja 4

Sekcja 5

Sekcja 12

Sekcja 13

Sekcja 14

Sekcja 15

Sekcja 16

Sekcja 17

Sekcja 18

Sekcja 19

Sekcja 20

Sekcja 21

Sekcja 22

Sekcja 23

Sekcja 24

Podsumowanie

Please choose the method of payment:*

Prepayment: bank transfer to our bank account

PayPal and/or Credit Card payment

Data for Payment (in €):
Beneficiary: Phytomedica Polska,
Bank Account No: PL 92 1240 1040 1978 0011 0052 3699
BIC (SWIFT Code): PKOPPLPW

Please notice: To the order total value a lump sum of €6,00 for package and postage cost shall be added.