Medicines/prescriptions

Long-term prescriptions and medication can be easily and conveniently ordered online from home using this form. We will then provide you with what you need. However, please wait with the collection until you have received a confirmation from us.

For an online order, we assume that you are already known to us as a patient and registered with us.

First name

Last name

Date of birth

E-mail (optional)

I wish...

medicine/s

Recipe

Medicine 1

Form of the medicine 1

Package size Medicine 1

Medicine 2 (optional)

Form of the medicine 2 (optional)

Package size Medicine 2 (optional)

Medicine 3 (optional)

Form of the medicine 3 (optional)

Package size Medicine 3 (optional)

Medicine 4 (optional)

Form of the medicine 4 (optional)

Package size Medicine 4 (optional)

Medicine 5 (optional)

Form of the medicine 5 (optional)

Package size Medicine 5 (optional)

Remarks (optional)

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Medicines/prescriptions

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