Application form for a contractual customer

In order to become a contractual customer, which gives the opportunity to place orders by telephone and e-mail, please fill in the form below. Fill in the fields and press the SEND button. Your application will be reviewed, and if everything meets the requirements, you will be registered as a customer. If you also want to get access to the Mediq OÜ business customer order portal, fill in the corresponding field on the form, and our sales department will contact you.

Form for becoming a customer

Please provide the following information to become a regular customer. Fields marked with an asterisk are required.

Accounting person

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