*Fields are mandatory

NAME OF CENTER*

CONTACT PERSON*

MODEL INDIBA®*
 activ 701 activ 801 activ 902

SERIAL NUMBER*

ADRESS*

POSTAL CODE*

CITY*

PHONE 1*

E-MAIL*

WEBSITE*

TRAINING RECEIVED*
 YES NO

 Physiotherapy and Rehabilitation Pelvic Floor Physio-aesthetics

In accordance with the provisions of art. 5 of Law 15/1999 on Protection of Personal Data (LOPD), we inform you that your personal data will be part of a file holder which is INDIBA SA, in order to manage our customer database and suppliers.
It also explicitly authorize that your personal and professional data provided in this form will be posted on our website, which lists the ratio of companies that sell products INDIBA.
You can exercise your rights of access, rectification, cancellation and opposition by written notice, attaching photocopy of identity card or equivalent identification document, to INDIBA SA C / Moianés, 13 - Pol Ind Casablancas -.. 08192 Sant Quirze del Vallés (Barcelona) - Spain. You can also exercise their rights by sending an email signed with electronic signature to the address info@indibaactiv.com