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Ordering a prescription

(patients of our office only)
Your input is kept strictly confidential (see Copyright).

First & last name
Date of birth
E-mail
Street
ZIP, city
Next checkup in our office	already booked due in 1 - 3 months due in 4 - 6 months due in 7 - 12 months
Type	Repetition First prescription
Which medication

Please phone us or send a fax, if we have not contacted you within three working days after sending your mail. Please note that there can be a delay due to vacations, and consult our substitute or your family doctor in case of urgency.