Martins Marsevskis Anton Fedorov & Yulia Chibisova GbR

Fedorov Restore Vision Clinic

DOB 22.11.1987 Prenzlauer Allee 90,
10409 Berlin (Germany)
Address Raunas iela 45/k-5, Riga LV-1084 Phone +49 30 20649289
Fax +49 30 81861357
Cell +49 151 52537003
E-mail: secretary@restorevisionclinic.com
Country Latvia www.restorevisionclinic.com

Ihr Zeichen Unser Zeichen Name Durchwahl Name

002211-230116 Marsevskis +493081861357 Anton Fedorov

Berlin, den 20.03.2023

PROFORMA-INVOICE
in relation to Medical Contract Nr: 002211-230116

Patient: Martins Marsevskis

Payment for the treatment using Electrical Stimulation Therapy

planned from: 27.03.2023 till 06.04.2023

Description Date Amount Total EUR

1 Case review 20. Januar 2023 550,00 550,00

2 Prepaid Deposit Payment 17. Februar 2023 980,00 980,00

3 Prepaid Payment 0,00 0,00

Paid in total 20.03.2023 1530,00

To be paid 8050,00

None paid balance 6520,00

Total to pay 6520,00

Bank details: Account Holder Anton Fedorov and Yulia Chibisova GbR
Bank Institute Deutsche Bank Privat und Geschaeftskunden
Address Schoenhauser Allee 120, 10437 Berlin, Germany
Account Number 088070800
IBAN DE59100700240088070800
SWIFT/BIC DEUTDEDBBER
Your reference number 002211-230116
While processing the payment follow these strict rules to avoid any issues receiving your money:
1. As a name of account holder only „Anton Fedorov and Yulia Chibisova GbR“ is accepted
2. Address of the bank is only „ Schoenhauser Allee 120, 10437 Berlin, Germany“
3. Add always the reference number (written above) which allows identify you

Alternatively, payment can be made with card. We accept Visa, Master Card, American Express debit and credit cards. We would like to stress
that in case of card payment you will additionally be charged an international bank fee of 3%. To process online payment please send us card
number, expiring dates, secure code. If you would like to pay via the PayPal system, please let us know so that we can send you a PayPal
invoice. Please note that PayPal charges a 6% fee.

Cancelation policy. The fee for our review of your medical case is not part of the cost for treatment, and will not be deducted from your
treatment fee; should you be eligible for treatment. The fee for our medical review is non-refundable regardless of the results of our review
(i.e., whether you qualified or not for treatment). If we have not yet started our review of your medical records, you can revoke your request
to review by sending us an email. We will return your payment. If we have already initiated our review of your records, however, a refund will
not be granted.

FEDOROV RESTORE GESCHÄFTSFÜHRER DEUTSCHE BANK VAT DE313750860 www.restorevisionclinic.com

VISION CLINIC DR. ANTON FEDOROV PRIVAT UND secretary@restorevisionclinic.com
Fedorov and Chibisova GbR GESCHÄFTSKUNDEN
Prenzlauer Allee 90 GESCHÄFTSFÜHRERIN DE59100700240088070800
10409 Berlin Germany DR. YULIA CHIBISOVA BIC DEUTDEDBBER
Phone/Fax: 030 81861357 GESCHÄFTSFÜHRER

Proforma Invoice Fedorov Restore Vision Clinic Marsevskis 22.11.1987 PAGE 1 OF 1

           
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