Prescription Orders – For Our Patients Only

Here you can request standing or repeat prescriptions. To ensure we can process your request correctly, we need both your name and your date of birth.

First Name *

Last Name *

Phone *

E-Mail *

Date of birth (DD.MM.YYYY) *

What medications do you need? *

How would you like to receive your prescription?

I‘ll pick up the prescription/referral at the doctor’s office.

I would like to receive the recipe by mail.

By using this form, you consent to the storage and processing of your data. *

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