Pawel Tacik, M.D.

Email: pawel.tacik@betaklinik.de
Phone: +49 (0)228 90 90 750
Fax: +49 (0)228 90 90 75 752
www.betaklinik.de

Name*:
Callback number*:
Recall period:
Subject:
Message*:
Security code*:	45ml + 80ml = (number+unit, example: 12ml):
	Yes Declarations of consent read and accepted.

Name*:
City:
Phone*:
Email*:
Weekday:	Mo Tu We Th Fr
Recall period:
Contact:	Call-back E-mail
Message*:
Security quiz*:	12cm + 27cm = (number+unit, example: 12cm):
	Yes Declarations of consent read and accepted.