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Online Test Request
Test request
Information about the request procedure
Test request form
Name *
Institution *
Department
Address *
ZIP code *
City *
Country *
Email *
Billing address *
same as address above
different from address above
Name *
Institution *
Department
Address *
ZIP Code *
City *
Country *
Email *
VAT
Netherlands (BTW 21%)
EU (VAT 0%, deferred, VAT number required)
Non-EU (VAT 0%, deferred)
VAT number *
Patient ID *
Purchase order
Cost centre code *
Project code
Remarks
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Conditions of Use
for this service.
Security *
* obligatory fields
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