Prescriptions

Prescriptions

    Name*

    First name*

    Date of birth*

    Street + street number*

    Postal code*

    City*

    Phone

    E-Mail*

    Request for prescription

    Please specify the medication (name, dosage and number of pills), e.g. Gabapentine, 300 mg, 100 pills

    Name of medication

    Dosage

    Number of pills

    more medicine

    Cure


    Data privacy*

    * required fields