Order prescription / referral for:   Quartal 2/21  (01.04. - 31.06.21)

Name, First name


ZIP             City


Mobile / Phone

Birth date

Health insurance


Referral to

I will pick up my prescription by myself

Send me the prescription / referral via postal

I have already visited the clinic during this quarter and my insurance card was scanned.
Your message

Sava data

  Please fill out all fields.
Copyright © 2018 | Impressum | Datenschutz
englisch | deutsch