Course*:
Please choose...Wednesday 7:00 p.m. - 8:00 p.m. (continous course)

First name*:

Family name*:

Street / no.

Postcode / Town

Telephone*:

E-mail*:

Health Insurance*:

Date of birth*:

Due date (expected date of birth)*:

* Please fill out the marked fields

Information of your medical insurance

I am statutory insured and will pay the course costs of 120€. I require a participation certificate, in order to apply for a 75% refund for the costs of preventions with my medical insurance.I am privately insured and wish a private medical bill in the amount of 140€ for the course costs, to refund with the insurance.I am a self payer und will pay 120€ course costs and do not require a participation certificate to refund with the medical insurance.

Information to your payment method

After receiving the booking confirmation (email) and at latest 2 weeks before course begin I will:

transfer the course costs to the following account number:

recipient: Vesna Lemm
subject: Pilateskurs
IBAN: DE63 3006 0601 0207 0269 00
BIC: DAAEDEDDXXX

If the payment is not made on time, the course spot will be given to next person on the waiting list.

Please notice: If you can't make it to your appointment please notify us 12 hours in advance (info@berliner-akupunkturpraxis.de).

If you miss an appointment without cancelling, the appointment cannont be repeated.

If you want to attend the course within a preventative measure of your medical insurance, it is necessary that we give you 8 appointments.

If you miss 1 appointment without cancelling, the costs of the whole course have to be taken over by you.

Comment / additional information:

I agree to the processing and the forwarding of the information I entered above. I can withdraw my consent at any time with immediate effect.