Prescription order form

Prescriptions for long-term medication

You have the option of ordering prescriptions for long-term medication online from us. No waiting time for the approval of prescriptions requiring authorization!

The prescriptions are ready for collection at the end of the surgery hours following the order (don’t forget your e-card).

Prescription order form

First name

Surname

4-digit insurance number

Date of birth 6 digits (DDMMYY)

E-mail address

Medication name

Dosage

Quantity

Medication name

Dosage

Quantity

Medication name

Dosage

Quantity

Data protection

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