Registration form

 

Registration form

Fields marked with an * must be filled out.
 
First name:*
Last name:*
Address:*
Address 2:
Zip code:*
City:*
Phone:*
E-mail:*
Estimated demand for test cards for 6 months:
Fax:*
Billing address of newborn screening cards submitted:
Enter caption:*

Upon filling out thisregistration form, you will be registered with us and will have the option to order test cards for newborn screening andinformational material.

To ensure that the logistics of the newborn screening proceeds accurately and optimally, we rely on having your complete address.

You can fill out the form online and send it in, or print out the PDF below and return it via fax or regular mail to:

Neugeborenen-Screening Schweiz
Universitäts-Kinderkliniken
Steinwiesstrasse 75
CH-8032 Zürich
Fax 044 266 81 10



Registration form as PDF

     Registration form in g only
 
created by inm.ch