Order i-Clinic

Complete the form below to order i-Clinic. The fields marked with * are required fields.
The undersigned hereby grants a general authorization to:

Bedrijfsautomatisering Holland
Het Fluitketeltje 12
NL-4207 WP Gorinchem
ING: 66.10.20.630
IBAN: NL46 INGB 0661 0206 30
BIC: INGBNL2A

to collect amounts of his/her bank account for the use of i-Clinic, the intelligent IT solution for your clinic.

Depreciation will occur on or about every first day of the month.

The undersigned is aware of the fact that, if he/she does not agree with the payment, he/she can ask his/her bank within 5 days to return the amount. The undersigned is also familiar with the fact that if he/she does not meet the monthly fee for the use of i-Clinic, the software can NOT be used until the monthly rent is paid. All this is provided for in our Service Agreement (SA) which is published on this website.
Clinic name *
Address *
Number *
Postalcode *
Place *
Country *
Other Country
E-mail address *
Telephone *
Cellphone
Contact *
Initials *
Prefix
IBAN Number *
Select the desired modules
Declarants *
Cloud users
Pro users
Promotioncode
Your monthly amount ex VAT is €
34