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Request prescription

Please send us your full name, date of birth, the name of the medication, and the dosage.

Has your insurance card already been scanned at our office in the current quarter? Yes No

Please note: A prescription or sick note (AU) request is only possible if your insurance card has already been scanned in our practice during the current quarter.

Full name *

Subject *

Phone

Email *

Geburtsdatum

Name of the medication *

Attach file

Submit

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