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Prescription request form

Last Name *

Initial(s)

 

 *
Date of birth * (dd-mm-yyyy)
Gender *

Name of medication *
Strength and dosage
Medication 2
Strength and dose med. 2
Medication 3
Strength and dose med. 3
Medication 4
Strength and dose med. 4
Are you a registered IHCH patient and has this medication been prescribed / dispensed by the IHCH pharmacy in the past?     *

If no, a consultation with a doctor is required before your request is processed. Please submit this form and an assistant will call you to schedule an appointment.
If order should be sent to another pharmacy, please state name, address and fax number
E-mail address *
Telephone number *
Comments/extra info
* compulsory question

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