Request for a prescription

You can use the following form for a prescription request.

The requirements are:


• You are a long-term patient 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

Note: This form cannot be used to order a prescription of controlled substances.

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Hinweis: Bitte die mit * gekennzeichneten Felder ausfüllen.