Request for a prescription

You can use the following form for a prescription request.

The requirements are:

• You are being treated at our doctor's office.

• You are on long-term medication.

You have presented your health card to the doctor's office this quarter of the year.



Prescription request form

Bitte den Code eingeben:

Hinweis: Bitte die mit * gekennzeichneten Felder ausfüllen.